
Class V 

Book_ 

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CfiESBlGHT DEPOStE 



THE PRACTICE OF 



PEDIATRICS 



BY 

CHARLES GILMORE KERLEY 

Professor of Diseases of Children in the New York Polyclinic Medical School and 
Hospital; Attending Physician to the New York Nursery and Child's Hos- 
pital; Consulting Physician to the Babies' Hospital; Consulting Physician 
to the Sevilla Home for Girls and to the New York Home for Des- 
titute and Crippled Children; Consulting Pediatrist to the Green- 
wich (Conn.) Hospital, to the Tarrytowm (N. Y.) Hospital, 
to the Englewood (N. J.) Hospital, and to the Lawrence 
(Bronx\-ille) Hospital; Ex-President American Pediatric 
Society; Ex-President New York County Medical 
Society 



SECOND EDITION. REVISED AND RESET 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1918 



TJ^ 



45" 



)T3g 
IS I g, 



Copyright, 1914, by W. B. Saunders Company. Reprinted July, 1914, February, 1915, and 
October, 1915. Revised, entirely reset, reprinted, and recopyrighted January, 1918 



Copyright, 1918, by W. B. Saunders Company 



h 






JAN i8i'9:i.8 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



©CI.A492015 



TO 

MY PRACTITIONER STUDENTS 

PAST AND PRESENT 



NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL, 

AT WHOSE SUGGESTION 

THIS WORK HAS BEEN PREPARED 



PREFACE TO THE SECOND EDITION 



The progress made in Pediatrics since the previous edition in 1914 
has necessitated many changes in this volume. Twenty^five new 
articles have been added, sixteen chapters largely re- written and 
lesser changes made in many others. A great deal of old material 
has been removed and in its place has been substituted that which it 
is hoped will be of more service to the practitioner and student. 

C. G. K. 

New York City, 
January, 1918. 



11 



CONTENTS 



Page 

The Newly Born 17 

Nutrition and Growth, 17 — Maternal Nursing, 21 — Human Milk, 31— 
Wet-nurse, 33 — The Breast, 34— The Nursery, 36 — The Nurserv-maid, 38 
—Weight, 38- Height, 41— The Care of the Stump of the Umbilical Cord, 
41 — ^Mental and Physical Development in the Infant, 42 — Baskets for 
Early Exercises, 44 — Crying, 44 — Sleep, 45 — Stools, 46— The Nursing- 
bottle and Nipple, 47 — Substitute Breast-feeding; Artificial Feeding, 
48— Cow's IMilk, 49— Modified Milk, 54— Cereal Gruels; Starch-feed- 
ing, 66 — Peptonized Milk, 68 — JMilk for Traveling, 69 — Food Formulas, 
70 — The Proprietary Foods, 71 — Cream, 73 — Sterilization and Pasteuri- 
zation of Milk, 74 — The Effect of Heating Milk upon its Assimilation, 77 
— Scientific Infant-feeding, 78 — Habitual Loss of Appetite, 79 — Sub- 
stitutes for Stomach-feeding, 81 — Disorders of Nutrition, 86 — IMarasmus 
(Arthrepsia; Infantile Atrophy), 86 — ^Malnutrition in Infants, 92 — The 
Ammoniacal Diaper, 100 — Tardy Malnutrition and Malnutrition in 
Older Children, 100 — Feeding after the First Year, 102 — General Proper- 
ties of Foods, 102 — Diet from the First to the Sixth Year, 105 — Diet 
after the Sixth Y^car, 108 — Diet during Illness, 109 — Common Errors 
in Feeding, 110 — Scurv^^ (Scorbutus), 111 — Rachitis (Rickets), 115 — The 
Delicate Child, 122. 

Examination and Diagnosis — Care of Acute Illness 130 

Diagnosis, 130— First Examination, 132 — Essentials in the Care of 
Acute Illness, 133 — The Sick-room, 137 — Necessity of Method in the 
Management of Children, 138 — Treatment of the Individual, 139. 

Diseases of the New-born 140 

Premature and Congenitally Weak Infants, 140 — Cephalhematoma, 142 
— Icterus, 143 — Sclerema, 145 — Sepsis, 146 — Asphyxia, 148 — Delayed 
.Asphyxia, 152 — Atelectasis, 152 — Amyotonia Congenita (Oppenheim's 
Disease), 153 — Congenital Absence of Bile-ducts, 153 — Umbilical Gran- 
uloma, 154 — Umbilical Polyp, 154 — IVIastitis, 155 — Tetanus, 156 — Hem- 
orrhagic Diseases, 157. 

Diseases of the Mouth and Esophagus 162 

Sprue (Thrush; Mycotic Stomatitis), 162 — Stomatitis, 163 — Cancrum 
Oris (Noma), 166 — Fissure of Lips, 167 — Geographic Tongue, 167 — 
Ulcerations and Fissvires at the Angle of the jMouth, 168 — Harelip and 
Cleft-palate, 168— The Teeth, 169— Malformation of the Esophagus, 171. 

Diseases of the Stomach, Intestines, and Peritoneum 172 

The Stomach, 172 — Acute Gastritis and Acute Gastric Indigestion, 173 — 
Chronic Gastric Indigestion (Chronic Gastritis), 175 — Chronic Dilatation 
of the Stomach, 176 — Ptoses and Dilatation of Stomach in Older Children, 
177 — Hemorrhage from the Stomach; Vomiting Blood, 182 — Ulceration 
of Stomach, 183 — Duodenal Ulcer, 184 — The Slanagement of Vomiting 
Babies, 185 — Pyloric Stenosis, 185 — Acute Gastro-enteric Intoxication, 
193 — Gastro-enteric Intoxication, 194 — Acute Enteric Intoxication, 201 
— Acute Intestinal Indigestion, 204 — Persistent Intestinal Indigestion, 
205 — Persistent Intestinal Indigestion in Older Children, 206 — Mechan- 
ical Agencies as Cause of Digestive Disturbances, 208 — Colic, 214 — Pre- 
vention of the Acute Intestinal Diseases of Summer, 216 — Vomiting, 
219— Rumination, 220— Acute Ileocolitis (Dysentery), 220— Chronic 
Ileocolitis, 227 — Mucous Colitis, 229 — Hirschsprung's Disease (Idio- 
pathic Dilatation of the Colon), 230 — Intestinal Infantilism of Herter, 
231 — ^Incontinence of Feces, 232 — Intussusception, 233 — Constipation, 
236 — Intestinal Obstruction, 244 — Intestinal Cysts or Diverticula (Con- 
genital), 246 — The Intestinal Parasites, 247 — Appendicitis, 252 — ^^Chronic 
Appendicitis, 255 — Acute General Peritonitis, 256 — Peritonitis as a 
Complication, 256. 

13 



14 CONTENTS 

Page 

The Rectum and Anus 258 

The Rectum in Children, 258 — Prolapse of the Anus and Rectum, 258 — 
Inflammation of the Anus, 260 — Fissure of the Anus, 260 — Proctitis, 261^ 
Ischiorectal Abscess, 262. 

The Spleen and the Liver 263 

The Spleen, 263— Splenomegaly, 263— The Liver, 263— Icterus (Obstruc- 
tive Jaundice; Catarrhal Jaundice), 265. 

Diseases of the Respiratory Tract 267 

The Nose and Throat, 267 — Acute Rhinitis (Coryza; Snuffles; Cold in the 
Head), 267 — Chronic Rhinitis (Nasal Catarrh), 269 — Nasal Hemorrhage, 
271— Throat Examination, 271— Persistent Cough, 272— Faucitis, 273— 
Pharyngitis, 274 — Retropharyngeal Adenitis, 275 — Acute Retropharyn- 
geal Abscess, 275 — Retropharyngeal Abscess — Tuberculous Caries of the 
Cervical Vertebra?, 278— Irrigation of the Throat, 278— The Tonsils, 279 
— Tonsillitis — Acute Follicular Tonsillitis, 280 — Peritonsillar Abscess 
(Quinsy), 283— Vincent's Angina, 285— Septic Sore Throat (Milk Borne), 
286 — Acute Catarrhal Laryngitis (Spasmodic Croup), 287 — Traumatic 
Laryngitis, 291 — ^Laryngeal Obstruction, 292 — Foreign Bodies in the 
Larynx, 292 — Adenoids, 293 — Hypertrophied and Permanently Diseased 
Tonsils, 297— Pollinosis, Pollen Disease, Hay Fever, 301— The Lungs, 302 
— Examination of Lungs, 302 — Bronchitis, 310 — Recurrent Bronchitis, 
314 — Acute Spasmodic Bronchitis (Bronchial Asthma), 316 — Pneu- 
monia, 320 — Lobar Pneumonia, 320 — Bronchopneumonia (Catarrhal 
Pneumonia), 332 — Interstitial Pneumonia, Including Bronchiectasis, 342 
— Hypostatic Pneumonia, 345 — Pneumothorax, 345 — Emphysema, 346 — 
Subcutaneous Emphysema (Emphysema of Mediastinum), 347 — Primary 
Pleurisy, 348 — Secondary Pleurisy, 348— Empyema (Pleurisy with Puru- 
lent Effusion), 351 — Pulmonary Gangrene, 360 — Pulmonary Abscess, 
360 — Pulmonary Tuberculosis, 361 — Heliotherapy, 366. 

Diseases of the Heart 368 

Diagnosis in Diseases of the Heart, 368 — Heart Murmurs, 370 — Peri- 
carditis, 374 — Acute Endocarditis, 377 — Myocarditis, 383 — Congenital 
Heart Disease, 386 — Acute Endocarditis, 378 — Chronic Valvular Disease 
of the Heart, 389 — Adherent Pericardium, 393. 

The Blood and Blood Diseases 394 

Blood in the Newly Born, 394 — Blood in Infancy or Childhood, 394^The 
Blood in Different Diseases, 397 — Blood-pressure in Children, 401 — 
Coagulation Time, 402 — Anemia, 402 — Chlorosis, 405— Pseudoleukemic 
Anemia of von Jaksch, 406 — ^Leukemia, 407 — Pernicious Anemia, 408 — 
Purpura, 409, Hemophilia (Bleeder's Disease), 411 — Hodgkin's Disease 
(Lymphadenoma), 413. 

The Glandular System 415 

Diseases of the Lymphatic Glands, 415 — Acute Cervical Adenitis, 415 — 
Persistent Simple Adenitis, 418 — Glandular Fever, 419: — Tuberculous 
Adenitis, 420— Mastitis in Young Girls, 422— The Thymus Gland, 423— 
Status Lymphaticus, 424 — Dyspituitarism. Dystrophy Adiposogenitalis 
(Frohlich), 428. 

The Urogenital System 429 

The Urine, 429 — ^Difficult and Painful Urination, 430 — Retention and 
Suppression of Urine, 430 — Incontinence of Urine (Enuresis), 432; — 
Hematuria (Blood in the Urine), 436 — Hemoglobinuria, 436 — Pyuria, 
436— Glycosuria, 437— The Kidneys, 438— Tuberculosis of the Kidney, 
438 — New Growths of the Kidney, 438 — Hydronephrosis and Pyonephro- 
sis, 439 — Cysts of the Kidney, 441 — Acute Parenchymatous Nephritis 
(Acute Diffuse Nephritis), 441 — Chronic Diffuse Nephritis, 449 — Chronic 
Interstitial Nephritis, 452 — Orthostatic AllDuminuria, 452 — Pyelocystitis 
(Pyelitis), 453 — Precocious Menstruation and Precocious Maturity, 456 — 
The Bladder, 457 — Cystitis, 457 — Vesical Calculus (Stone in the Bladder), 
458— Exstrophy of the Bladder, 458— The Male Genitals, 459— Balanitis, 
459 — Phimosis,"^ 460 — Paraphimosis, 461 — Circumcision, 461 — Unde- 
scended Testicle, 462— Orchitis, 462— Hydrocele, 463— Gonorrhea in the 
Male, 464 — Epispadias and Hypospadias, 464 — The Female Genitals, 465 
— Vulvovaginitis (Simple), 465 — Gonorrheal Vulvovaginitis (Specific 
Vaginitis), 466 — Atresia of the Urethra and Vagina, 469. 



CONTENTS 15 

Page 

Nervous Disorders 470 

Headache, 470 — Favor Diurnus, 470 — Night-terrors (Pavor Nocturnus), 
471 — Gyrospasm (Spasmus Nutans), 472 — H^^steria, 472 — Habits, 477 — 
Masturbation, 479 — Hiccup, 483 — Infantile Convulsions, 483 — ^Laryngis- 
mus Stridulus, 487 — Spasmophilia, 489 — Congenital Stridor, 491 — Tetany, 
491 — Insanity, 497 — Malformations of the Brain and Cord, 499 — Type 
and Incidence of Brain Tumor, 502 — Mentally Deficient Children (Imbe- 
cility; Idiocy), 503 — Mongolian Idiocy, 503 — Amaurotic Family Idiocy, 
507 — -Hydrocephalus, 509 — Cerebral Palsies — The Prenatal and Birth 
Forms, 513 — The Acquired Form, 515 — Chorea (St. Vitus' Dance), 518 — 
Habit Spasm (Tic), 524 — Stammering, 525 — The Progressive JMuscular 
Atrophies, 526 — Progressive Spinal Muscular Atrophy or Progressive 
Amyotrophy, 526 — The Progressive Amyotrophies (Primary Muscular 
Dystrophies). 530 — Epilepsy, 531 — x\cute Poliomvelitis (Infantile Paraly- 
sis), 535— Multiple Neuritis, 542— Facial^ Palsy, 546— Erb's Palsy 
(Obstetric Paralysis), 547 — Friedreich's Ataxia (Hereditary Ataxia), 548 — 
Acute Infective Meningitis, 550 — Tuberculous Meningitis, 553 — Cerebro- 
spinal Meningitis, 557 — Meningismus (Serous Meningitis), 565 — ^Lumbar 
Puncture, 566. 

Diseases of the Skin 568 

Miliaria (Prickly Heat), 569 — Urticaria (Hives; Nettle-rash), 570 — Rhus 
Poisoning (Ivy Poisoning), 571 — Scabies (Itch), 572 — Furunculosis 
(Boils), 573 — Pediculi (Head Lice), 514 — Tinea Circinata (Ring-worm), 
575 — Tinea Tonsurans (Ring-worm of the Scalp), 576 — Impetigo Contag- 
iosa, 579— Pemphigus Neonatorum, 579 — Erythema Nodosum, 580 — 
Er^'thema Multiforme, 581 — Erysipelas, 581 — Eczema, 584 — Eczema 
Intertrigo or Erythema Intertrigo, 590 — Eczema in Older Children, 591 — 
Seborrhea, 595 — Psoriasis, 597 — Bed-sores (Decubitus), 597 — Ne^'Tls 
Birthmark), 598. 

Diseases of the Ear 600 

Earache, 600 — Deafness, 600 — Acute Otitis, 601^ — Chronic Suppurative 
Otitis, 605— IMastoiditis, 606— Sinus Thrombosis, 606. 

The Transmissible Diseases 608 

Care to be Exercised b}^ Physician in Visiting Infectious and Contagious 
Diseases, 609 — Varicella (Chicken-pox), 609 — r^Iumps (Epidemic or Spe- 
cific Parotitis), 611 — Whooping-cough (Pertussis), 614 — Measles, 619 — 
German INIeasles (Rotheln; Rubella), 624 — Diphtheria, 625 — Scarlet 
Fever (Scarlatina), 643 — Tj^phoid Fever, 657 — Malaria, 666 — Influenza, 
670— Syphilis, 677 — Acute Hereditary or Congenital Syphilis, 678 — Ac- 
quired Syphilis, 685 — Tardy Hereditary Syphilis, 685 — Tuberculosis, 
691— Abdominal Tuberculosis (Tuberculosis of the ^Mesenteric Gland; 
Tabes Mesent erica), 694 — Chronic Tuberculous Peritonitis, 695 — Dac- 
tylitis, 699 — The Newer Diagnostic Methods, 701 — Tuberculosis, 701 — 
Tuberculin Skin Reactions, 703 — Wassermann Test for Svphilis, 704 — 
Noguchi Butyric-acid Test for Syphilis, 705— Luetin Test, 706— The 
Widal Reaction for Typhoid Fever, 707 — Anaphylaxis, 708. 

Unclassified Diseases 709 

Rheumatism, 709 — Acidosis, 713 — Cyclic Vomiting (Recurrent or Peri- 
odic Vomiting), 715 — Cyclic Diarrhea, 719 — Periodic Fever, 720 — Rheu- 
matic Fever (Acute Rheumatism), 721 — Rheumatoid Arthritis; Arthritis 
Deformans; Still's Disease, 724 — Chondrodystrophia (Achondroplasia), 
725 — Cretinism (Infantile INIyxedema; Cretinoid Idiocy), 727 — Dwarfs, 
733 — Diabetes Insipidus, 734 — Diabetes Mellitus, 735 — Acetonuria in 
Children, 737— Pellagra, 738— Beriberi, 740. 

Miscellaneous Subjects _. 743 

Heredity and Environment, 743 — Consanguinity, 744 — Temperature in 
Children, 744 — Obscure Elevations of Temperature, 747 — Anesthetics, 
750 — Carcinoma, 751 — Obesity, 752 — Hematoma of the Sternocleidomas- 
toid, 752 — Hernia at the Umbilicus, 753 — Hernia of the Umbilical Cord, 
753— Congenital Umbilical Hernia, 754 — Inguinal Hernia, 755 — Ventral 
Hernia, 756 — Diagnosis in Bone and Joint Diseases, 757. 

Suggestions in ^lanagement 760 

Vaccination, 760 — Davs to go Out-of-Doors; Indoor Airing, 762 — Instruc- 
tions for the Summer, 763 — The Exercise Pen, 767 — Summer Resorts, 
768— Foreign Bodies Swallowed, 768. 



16 CONTENTS 

Page 

Therapeutic Measures » » 771 

Therapeutics in Children, 771 — The Therapeutic Value of Climate, 773 — 
Counterirritants, 775 — Cold Sponging in Fever, 776 — The Cool Pack, 
777 — Baths, 778 — Bathing the Sick, 781 — Unpalatable and Nauseating 
Drugs, 781 — Alcohol, 783 — Heat as a Therapeutic Agent, 78^ — Cold as a 
Therapeutic Agent, 785 — Blood Transfusion and Intramuscular Injection, 
786— Lavage — Stomach-washing, 788 — Gavage, 790 — Colon Irrigation, 
793 — Colon Flushing, 795 — Hypodermoclysis, 796 — Vaccine Therapy, 
797. 

Gymnastic Therapeutics 803 

Rules, 803— Posture and Breathing, 806— Breathing, 812— Flat Chest, 815 
— Kyphosis, 817 — ScoHosis, 820 — Empyema, 825 — Emphysema, 827— 
Congenital Ataxias, 829 — Anterior Poliomyelitis, 841 — Constipation, 
843— Flat-foot, 844. 

Drugs and Drug Dosage 847 

Drugs for Internal Use, 847 — Drugs for External Use, 859. 



Index . . „ , 865 



THE PRACTICE OF PEDIATRICS 



I. THE NEWLY BORN— NUTRITION— GROWTH 
Nutrition and Growth 

The fundamental principles in the life of the young of all animals 
are growth and development. This statement applies to the young 
of the lower animals as well as to man. Nature has fixed and definite 
laws in accordance with which this growth and development proceed. 
The type of animal produced depends in no small degree upon the way 
in which we comply with nature's laws. 

Heredity. — Heredity is, of course, an important factor, but environ- 
ment counts for more. The young of the lower animals or of man may 
possess all that can be desired in the way of heredity, but if manage- 
ment during growth is faulty, the adult is almost certain to fall short 
of the normal. On the other hand, an individual without the benefits 
of good heredity, when given the advantages of faithful scientific care 
may develop into an adult decidedly superior in all respects to those 
more fortunate in birth. I have seen this demonstrated repeatedly, 
both in the lower animals and in man. 

Environment. — From my earliest recollection I have carefully 
watched the growth and development of animals. By observing care 
as to feeding, housing, ventilation, cleanliness, and exercise, I have seen 
animals which promised but little at birth develop into perfect mature 
specimens of their kind. During the past twenty-eight years I have 
been intimately associated with thousands of infants and growing 
children in private, in hospital, and in out-patient work. The possi- 
bilities of proper growth under good management when little was to be 
expected, judging from the original condition of the patient, have been 
impressed upon me repeatedly. 

The child is here through no choice of his own. He is to have a 
future. His health, vigor, powers of resistance, happiness, and useful- 
ness as a citizen are determined in no small degree by the nature of his 
care during the first fifteen years of life. He has a right to demand that 
such care be given him as will be conducive at least to a sound, well- 
developed body, and this should be our first thought and object regard- 
ing him. Consider for a moment the number of occupations, other 
than those of the army and the navy, which require physical fitness 
before a candidate is accepted. Competition is keen at the present 
time and will be keener in the future. Employers of men and 
women, whether in the office, the factory, or on the farm, cannot 
afford to employ the physically weak. 
2 17 



18 THE PRACTICE OF PEDIATRICS 

The most important factor in the making of men and women is 
nutrition. No great power of reasoning is required to appreciate the 
fact that the child who is fed on suitable food will become a more vigor- 
ous, better developed adult than one who, beginning with his birth and 
continuing throughout the entire period of his growth, is given only 
food possessing indifferent qualities for tissue building. Next in im- 
portance to food, and following in close succession, are fresh air, clean- 
liness, cheerful surroundings, and healthful amusements, together with 
an absence of school work or service of an arduous nature. That the 
offspring of man suffers more from nutritional errors due to the lack 
of suitable care than do the young of the lower animals is lamentable, 
but nevertheless a fact. The absence of thought and care and of 
knowledge relating to children is due to the fact that the child as such 
has apparently no intrinsic value in dollars and cents, whereas the 
young of the lower animals represent no small part of their owner^s 
material possessions. 

Feeding. — Success in the entire management of children demands 
daily attention to detail. Feeding the child properly one or two 
months out of the year is of little value. He should be fed properly 
every day in the year, for under normal conditions every day is a day of 
growth. Another factor having a deterrent influence upon the devel- 
opment of children is their unfavorable start during the first year. 
Unfortunately many mothers cannot supply to the infant the requisite 
nourishment. This brings us to the matter of substitute feeding, 
fraught with perplexities and uncertainties in the most competent 
hands, and with dangers and disasters in the hands of the incompetent 
and inefficient. In the chapter on Substitute Feeding in infants their 
nutrition is considered in detail. It is sufficient to remark here that 
nature has provided for the baby a food which contains the nutritional 
elements, fat, sugar, and proteid, in fairly definite proportions and in 
peculiar forms. Success in substitute feeding depends upon our ability 
to supply in suitable forms, and the child's ability to assimilate, a food 
containing the nutritive elements in approximately the quantities 
found in human milk. An exact reproduction of mother's milk by the 
use of cow's milk or other food is, of course, impossible. We can 
imitate human milk, however, with sufficient accuracy to make accept- 
able and sufficient food for most children who are deprived of the breast. 
After the nursing or the bottle age, the feeding must not be left to the 
family judgment, for at this period of rapid growth suitable nutrition is 
most important. Left to the family, the diet during the second year 
too frequently consists of milk, which in large cities is often of uncer- 
tain nutritive value, together with insufficiently cooked cereals, boxed 
breakfast foods, bread-stuffs, crackers, and cake — often procured at 
the grocer's or baker's. At the out-patient departments of the New 
York Babies' Hospital and the New York PolycHnic Medical School, 
only 20 per cent, of the children treated who are over one year of age 
are of normal development. In those under one year of age, only 35 
per cent, are normal. While these children are not to be considered as 



NUTRITION AND GROWTH 19 

representing the country as a whole, still they do represent a large part 
of the population of our larger cities. These children are the offspring 
of day-laborers, drivers, waiters, and small-wage earners generally. 
Such children were fed in the manner above described, not because of 
poverty, but because of an absence of the slightest knowledge on the 
part of the parents regarding suitability of foods. The children were 
not hungry; they were fed to satisfy the appetite; but when that was 
accomplished the parents considered their duty done. To feed with a 
definite purpose — with a view solely to the physical development of 
their children — had never entered the minds of the parents, yet most of 
them could read and write and possessed a fair degree of general intelli- 
gence. They were conversant with affairs and had attended the public 
schools, but were absolutely untaught as to how they should live. 

Selection and Preparation of Food. — The diet during this period of 
early childhood should be highly nutritious, and, in order to be properly 
digested, food should be given at definite intervals. It should be well 
cooked and properly seasoned. The habit of allowing children to eat 
between meals cannot be too strongly condemned. It not only spoils 
the appetite for suitable food at regular hours, causing children to crave 
delicacies, but prevents complete digestion and assimilation. The 
active '^ runabout" child and the school-child require a high proteid 
diet. This should consist of red meat, never oftener than once daily, 
poultry, fish, eggs, milk, butter, cream, whole- wheat bread and cereals, 
such as oatmeal, cracked wheat, cornmeal, and hominy. For the sake 
of variety other cereals may be used. Each cereal mentioned should 
be cooked three hours the daj^ before using. It may be claimed that 
the prolonged cooking is impossible to secure. It is done, however, in 
dozens of families under my professional care. Green vegetables and 
stewed and raw fruits are important adjuncts to the dietary. Dried 
peas, beans, and lentils in the form of a puree are valuable articles of 
nutrition because of their large percentage of vegetable proteid, and 
they are particularly useful in children with a rheumatic tendency, for 
whom the use of red meat must be curtailed. 

Fresh Air — iDoubtless the next most important factor after food 
and the means of giving it is good air. It is a just criticism of the 
average American that he is afraid of fresh air, not only by night but by 
day. Ventilation is one of the most difficult features of a child's 
management with which I have had to deal. Mothers will feed the 
children in detail according to instruction. They will bathe them and 
follow out to my satisfaction every order and direction. The stumb- 
ling-block is the open window. If the mother opens it as directed, 
the grandmother or some other member of the family appears on the 
scene and closes it. The window-board (p. 138) and other means of 
ventilation on the market have their uses. The window-board in my 
hands has been most satisfactory. It is to be hoped that a knowledge 
of the means and results of treating tuberculosis by open-air methods, 
and the recent agitation concerning the treatment of pneumonia and 
other infectious diseases along similar lines, may so permeate the minds 



20 THE PRACTICE OF PEDIATRICS 

of the masses as to quiet their fears regarding dangers of outdoor 
air. 

In my own experience I have been able to secure an ample supply 
of fresh air either by the window-board, already referred to, or the 
open fireplace. While the child is out of the living-room or nursery, 
the room should be ventilated by opening all the windows, when family 
conditions allow, the nursery always being aired in this way. The 
sleeping-room should always be aired for one hour before the child is 
put to bed. Indoor airing for which the child is dressed as for going 
out, placed in his carriage or cart, and wheeled up and down the room 
for an hour or two with the windows wide open regardless of the 
weather, is most satisfactory in treating very young and delicate chil- 
dren, and promoting convalescence from illness. On inclement days 
the well child accustomed to his daily outing will be greatly benefited 
by the indoor airing. It is fully appreciated that such a course of 
management is impossible in many households. The scheme is the 
ideal one, however, and should be followed out as closely as possible. 

Bathing. — The necessity for the daily bath is appreciated and acted 
upon by nearly all classes of society. From the time the cord falls 
and the cicatrix forms, the well infant or child should have one tub- 
bath daily. If he is too ill for the tub, he is not too ill to be sponged. 

Work and Stress. — The well child is naturally good-natured and 
happy. When such is not the condition, we have not a well child to 
deal with. Something is wrong. Oftentimes it is the home manage- 
ment. Adults often forget that exuberance of spirits and thoughtless- 
ness belong to childhood. Persistent child-nagging becomes a habit 
with many parents and teachers ; in fact, irritable mothers usually have 
irritable children. Work involving strain, whether physical or mental, 
should form no part of the life of the child. In our modern school 
system the forcing process, the competitions, the giving of rewards of 
merit, are all pernicious practices. As a result of the competitive 
system, progress, to be sure, is made along intellectual lines, but at the 
expense of the physical; and what does intellectual attainment count 
for in a weakly or diseased body? A child cannot do hard mental work, 
such as is required of many children from the tenth to the fifteenth 
year, and be expected at the same time to develop to the best advantage 
physically. The appetite and digestive powers, the capacity for taking 
and assimilating food, are diminished. I have seen the result in hun- 
dreds of cases. On the streets in New York two pictures always fill 
me with pity. One is that of the pale, slender school-girl struggling 
home with a load of books. Such a child who came to me recently 
had 11 text-book studies besides piano and dancing lessons! When 
the question is asked the child or the parents as to the necessity for all 
this work and worry and the close confinement which it entails, the 
reply almost invariably is that all the girls of her age do the same and 
she does not want to be behind. The other picture is that of the "little 
mother" — a pale, wan, tired child from seven to twelve years of age 
who "minds the baby" and the other younger members of the house- 



MATERNAL NURSING 21 

hold while their mother is away from home or at work. Children so 
abused are happily growing fewer, owing to various factors which need 
not be discussed. It is needless to say that neither type of girl makes 
the ideal woman or mother in any station in life. The condition of 
boys who work in factories, sweat-shops, or elsewhere is no better. 
When too much energy is expended in work, it cannot go to the build- 
ing of a strong, normal body. The State is the loser and the child is 
robbed of his birthright. 

It is the duty of physicians having children under their care to 
explain in detail to parents their responsibility as regards the physical 
welfare of their children. Parents, as a rule, are ignorant concerning a 
child's management; but they are anxious and willing to do the best 
things possible, and will carry out suggestions if we take the trouble to 
enlighten them as to their errors. 

MATERNAL NURSING 

Writers on this subject are very prone to state that the ability of the 
mother, particularly among the well-to-do, to fulfil this most important 
function is surely decreasing. This may have been a true statement 
fifteen or twenty years ago ; at the present time, however, I am sure it 
is erroneous. In my own medical life I have seen a change for the 
better, particularly during the past fifteen years. The young mother 
of today is better able to nurse her offspring than was her sister fifteen 
or twenty years ago. I attribute this to the fact that the youth of the 
present day are more vigorous, more nearly normal individuals than 
were those of an earlier date. The inability to perform the nursing 
function so that it will be successful has always been attributed to the 
mother ipse. This, I think, is an error. A child born with a generally 
enfeebled vitality, keenly feels any slight abnormality in the milk, or 
may not be able to digest perfectly normal milk; in either event, the 
milk disagrees and the nursing is discontinued. Not every breast-milk 
for two or three weeks after parturition is ideal, as I have found by the 
examinations of hundreds of specimens. Breast-milk during the first 
two or three weeks of the infant's life is produced under unfavorable 
conditions which do not indicate the possibilities of the breast as a 
secreting organ. Early nursing following, as it does, upon the stress 
of confinement, is not indicative of what may be possible later when the 
customary life and daily habits are resumed. Repeatedly I have found 
a very high fat or a high proteid, or both, entirely corrected after the 
first week or two, without interference. This condition at the time was 
considered sufficiently serious to warrant the discontinuance of nursing 
on the part of a weakly infant, while in a vigorous infant it would be 
entirely ignored. 

The change which enables more mothers successfully to nurse their 
infants is due to two causes-^more vigorous fathers and mothers and 
more vigorous offspring. The more normal the mother, the better 
able is she to perform this normal function. That this is the case is 



22 THE PRACTICE OF PEDIATRICS 

due, I believe, to the fact that growing girls and young women are 
leading more hygienic lives than formerly. The making of golf, 
bicycle and horseback riding, boating, and automobiling popular and 
fashionable — in short, the taking of girls out-of-doors and keeping them 
there a considerable portion of the day — has worked a marvelous 
change for the better, both physically and mentally. A neurotic 
mother makes the poorest possible milk-producer. Proportionate to 
the population, there are fewer neurasthenics among the young women 
today than there were twenty years ago, and there will be still fewer 
twenty years hence. At the present time the timid, retiring young 
woman of the neurasthenic type is not popular in her set. It is for- 
tunate for the future of the human race, at least for that portion which 
resides in the United States, that the young woman has transferred her 
allegiance from the crochet and embroidery needle to out-of-door sports. 
It may be said that our argument holds only with the wealthy or the 
well-to-do. Imitation is one of the strongest characteristics of the 
human race, and this tendency in America to outdoor hygienic living 
pervades all classes. Saturday half-holidays, and the excursions and 
outings afforded by reduced rates in transportation, are much more 
popular than they were twenty years ago. Food is better selected and 
better prepared, owing to increased knowledge on the part of the people 
as to what constitutes proper nutrition. These are facts, in spite of the 
sensational novelists and magazine-writers. 

A feature which marks an important advance in the right direction 
is the establishment of a department in dietetics and food economics 
in the New York Training School for Teachers. The Dean, Dr. James 
E. Russell, in establishing this course is producing benefits which per- 
haps are more far-reaching than he realizes. The students are taught 
food values, food preparation, and food economics, the science of pro- 
viding for a given amount of money the most nutritious food in its most 
attractive form. Of the hundreds of teachers sent out from this insti- 
tution every year to take their places of usefulness as instructors of the 
young in all portions of the country, each has learned something of 
food values, and, better still, each has been impressed with the impor- 
tance, to a growing child, of proper nutrition, without which the best 
possible type of adult cannot be produced. As a result of such in- 
struction these teachers will be of far greater service in their fields of 
labor; for not only can they teach what is laid down in the books, but, 
what is equally if not more important, they are competent to teach 
those under their care so to live as to attain proper growth, following 
out the maxim of Herbert Spencer that " the first requisite for success 
in life is to be a good animal ; and to be a nation of good animals is the 
first condition of national prosperity.'' It may be thought that we 
have wandered far from our subject, — maternal nursing, — but such 
is not the case; for conditions which relate even remotely to this im- 
portant function demand our respectful consideration. The food 
and care of the growing girl have the most intimate bearing upon her 
future life, and if she is to be called upon to perform the most impor- 



MATERNAL NURSING 23 

tant function of womanhood, she surely has the right to demand that 
she receive during her girlhood proper preparation, which heretofore 
has too often been denied her. 

The family physician does not, in a great majority of instances, fulfil 
his function, or extend his field of usefulness to its full capacity, his 
conception of duty too often including only the care of the sick. Un- 
sought advice concerning the feeding and daily habits of a child's life, 
I find is usually welcomed and appreciated by the parents. In practi- 
cally every instance, according to my observation, errors in a child's 
management are due to ignorance. Parents, no matter w^hat their 
station in life, are glad to do what is for the best interests of their 
children when the situation is made clear to them. It is our duty to 
take parents into our confidence and explain to them the reasons for the 
line of action advised. When they appreciate the reason for certain 
procedures, I find that they are far more apt to follow them. I am 
confident, from observations upon many cases, that if I could have the 
physical direction of ten average girls in any station in life, provided that 
they could have the benefit of fresh air and good food from infancy to 
adolescence, successful nursing mothers could be made out of eight of 
them. Certain rules of life having a direct bearing on nursing lead us 
nearer the ideal and may enable one who otherwise could not nurse her 
child to do so successfully. These requirements, it will be seen, are laid 
along common sense lines and cause no hardship or mental distress, one 
of the chief requirements of a nursing woman being that she shall be 
mentally normal. 

Few functions with which we are called to deal are so variable and 
uncertain as the production of breast-milk. Breast-milk is one of the 
most precious substances. It is invaluable — unless we can put a value 
on human life. The most successful nursing age is between the twen- 
tieth and thirty-fifth years. I have, how^ever, seen successful nursing 
carried on in a girl of fourteen, in a woman of fifty-two, and in the 
much abused society girl, while I have seen it fail absolutely in peasant 
women fresh from the fields of Hungary and Bohemia. I have seen 
those whose nursing at first was most unsatisfactory develop into per- 
fect nurses. 

Some mothers will be able to carry on the nursing for only two 
months : others, three, five, seven, or nine months. In my experience 
in both out-patient and in private practice it is extremely rare for the 
breast milk to be sufficient for a child after the ninth month. A most 
unusual record in nursing is that of an Italian woman who nursed 
uninterruptedly and successfully three infants of her prolific employer. 
The first two children were each nursed for one year, the third child 
for ten months. Even then the supply had not diminished, but 
nursing was discontinued because of illness of wet nurse. 

The following may be laid down as nursing axioms : 

A diet similar to that w^hich the mother was accustomed to before 
the advent of motherhood should be taken. 

There should be one bowel evacuation daily. 



24 THE PRACTICE OF PEDIATRICS 

From three to four hours daily should be spent in the open air in 
exercise which does not fatigue. 

At least eight hours out of every twenty-four should be given to 
sleep. 

There should be absolute regularity in nursing. 

There should be no worry and no excitement. 

The mother should be temperate in all things. 

The Diet. — Many times, when consulted by nursing mothers be- 
cause the nursing was unsuccessful or a partial failure, I have found 
that their diet had been restricted to an extreme degree. To put on a 
greatly restricted diet a robust young mother who has always eaten 
bountifully of a generous variety of foods is one of the best means of 
curtailing the quantity and lowering the quality of her milk-supply. 
When asked to prescribe a diet I tell such mothers to eat as they were 
accustomed to before the advent of pregnancy and motherhood. That 
this particular vegetable or that particular fruit should be forbidden on 
general principles is a fallacy. Food that the patient can digest with- 
out inconvenience is a safe food so far as the nursing is concerned, as 
may readily be determined in any given case. For certain individuals, 
however, a plain, more or less restricted diet is desirable. This must 
be remembered in the management of the wet-nurse (p. 33). Many a 
wet-nurse who has been carefully selected, and who to the best of our 
judgment should prove satisfactory, utterly fails in a few days to fulfil 
the duties of the office for which she was chosen. In not a few in- 
stances the failure is due to a very full diet of unusual articles of food, 
the existence of which, in many instances, she never dreamed. Indi- 
gestion and constipation follow, both the nurse and the baby are made 
ill, and the woman's usefulness ceases. A woman who has lived and 
kept well on the diet and food found in the home of the laboring man, 
whether in the city or country, will make a far better wet-nurse on this 
diet than if she indulges in food to which she is entirely unaccustomed. 
In general, the diet of a nursing mother, then, should be that to which 
she has been accustomed. 

Nursing is a perfectly normal function, and a woman should be per- 
mitted to carry it out along only natural lines. Inasmuch as there 
are two lives to be provided for instead of one, more food, particularly 
of a liquid character, may be taken than the mother may have been 
accustomed to. It is my custom to advise that milk be given freely. 
A glass of milk may be taken in the middle of the afternoon and eight 
ounces of milk with eight ounces of oatmeal or cornmeal gruel at bed- 
time, if it does not disagree with the patient. Our only evidence that a 
food is not disagreeing is the condition of the digestion. When any 
article of food disagrees with the mother, or if she is convinced that it 
disagrees, whether or not such is really the case, the food should be dis- 
continued. In a general way, milk in quantities not over one quart 
daily, eggs, meat, fish, poultry, cereals, green vegetables, and stewed 
fruit constitute a basis for selection. The method of preparation for 
the different meals is not arbitrary. 



MATERNAL NURSING 25 

The Bowel Function. — A very important and often neglected matter 
in relation to nursing is the condition of the bowels. There must be 
one free evacuation daily. For the treatment of constipation in nurs- 
ing women I have used different methods in many cases. The dietetic 
treatment does not promise much. For here, again, manipulation of 
the diet may interfere with the milk production. Three methods are 
open to use — massage, local measures, and drugs. Massage is available 
in comparatively few cases. Local measures consist in the use of 
enemas or suppositories. Every nursing woman under my care is in- 
structed to use an enema at bedtime if no evacuation of the bowels has 
taken place during the previous twenty-four hours. Many out- 
patients, in whom constipation is very prevalent, indulge in excessive 
tea-drinking, often taking from one to two gallons of tea daily. In 
treating such patients where an absolute discontinuance of the tea- 
drinking is often impossible and not absolutely necessary, I usually 
allow two cups a day. For a laxative in such cases and in many others, 
a capsule of the following composition has served well : 

I^ Extracti belladonnse gr- 3^ 

Extract! nucis vomicae gr. ^ 

Extracti cascarse sagradae gr. v 

M. et. ft. capsula No. i. 

Sig. — To be taken at bedtime. 

The amount of the cascara sagrada may be varied as the case may 
require. In not a few instances I have found it necessary to give two 
capsules a day in order to produce the desired result. Neither the 
belladonna, the nux vomica, nor the cascara appears to have any ap- 
preciable effect on the child. 

Air and Exercise. — Outdoor life and exercise are not only as desir- 
able here as they are under all other conditions, but to the nursing 
woman, with her added responsibility, they are doubly valuable. In 
order to get the best results, exercise or work should so be adjusted as 
not to reach the point of fatigue. The mother whose nights are dis- 
turbed should be given the benefit of a midday rest of an hour or two. 
She should have at least eight hours' sleep out of every twenty-four. 
Certain annoyances, anxieties, and worries are inseparable from the 
life of every child-bearing woman. It should be our duty, however, to 
explain to the mother and to other members of the family that an 
important element in satisfactory nursing is a tranquil mind. ' During 
the lactation period she should be spared all unnecessary care and petty 
annoyances. 

Regularity in Nursing. — The breast which is emptied at definite 
intervals invariably functionates better than does one which is not, not 
only as regards the quantity, but also the quality, of the milk; so that 
system in breast-feeding is almost as essential to milk-production as 
to its digestion and assimilation. 

After it is demonstrated that the nursing is progressing satisfac- 
torily, as proved by the satisfied, thriving child, I begin with one bottle- 
feeding daily. The advisability of this is obvious: in case of illness of 



26 THE PRACTICE OF PEDIATRICS 

the mother, if she is called away from home, or if, for any reason, the 
child cannot have the breast, the feeding is provided for. Another 
advantage of this provision is that it gives the mother needed freedom 
from restraint. She is thus enabled to have the benefit of a change of 
scene. Amusements and recreations which the invariable nursing 
period denies her can be indulged in. As a result of this greater free- 
dom she is able to supply better milk and to continue nursing longer 
than if tied continually to the baby, no matter how fond of the infant 
she may be. 

Frequency of Nursing.^ — From birth until the third month seven 
nursings in twenty-four hours are allowed as follows: 6 a. m., 9 a. m., 
12 M., 3 p. M., 6 p. M., 10 p. M., 2 A. M. From the third to the completion 
of the six month, six nursings as follows: 6 a. m., 9 a. m., 12 m., 3 p. m., 
6 p. M., 10 p. M. After the sixth month, and in large strong children 
after the fifth month, five nursings in twenty-four hours, as follows: 

6 A. M., 10 A. M., 2 p. M., 6 p. M., 10 p. M. 

Giving of Water. — From one-half to one ounce of a 1 per cent, 
solution of milk-sugar should be given the infant every three hours 
until the milk appears in the breast. Otherwise there will be unneces- 
sary loss in weight and perhaps a high degree of fever due to inanition. 

If the child is restless and uncomfortable, it is safe to conclude that 
he is thirsty; one ounce of the sugar water will usually satisfy him. 
With the commencement of nursing, the baby should be accustomed to 
getting his food at regular intervals. 

Signs of Successful Nursing. — The normal infant shows a gain of 
not less than four ounces weekly. This is the minimum weekly gain 
which may safely be allowed. When a nursing baby remains station- 
ary in weight or makes a gain of but two or three ounces a week, it 
means that something is wrong, and the defect will usually, but not 
invariably, be found in the milk-supply. When the baby is nursed at 
proper intervals and the supply of milk is ample and of good quality, he 
is satisfied at the completion of the nursing. Under three months of 
age he falls asleep after ten or twenty minutes at the breast. When 
the nursing period again approaches, he becomes restless and unhappy, 
crying lustily if the nursing is delayed. When the breast is offered, 
he takes it greedily. The stools are yellow and number from two to 
three daily. The weekly gain in weight under such conditions is usually 
from six to eight ounces. 

Signs of Unsuccessful Nursing. — Theoretically, every normal breast 
infant should be a thriving, well baby. That such is not the 
case, is an unfortunate fact. The standard established for a well baby 
is not upheld. When the supply of milk is scanty the child remains 
long at the breast and cries when he is removed. He shows signs of 
hunger before the nursing hour arrives. A cause of failure in breast- 
feeding, and probably the most frequent cause, is a scanty milk-supply. 
The chief nutritional elements in mother's milk are fat, 3 to 4 per cent. ; 
sugar, 7 per cent. ; proteid, 1 .5 per cent. Failure may be due to a marked 
disproportion of these elements, which may cause sufficient indi- 



MATERNAL NURSING 27 

gestion and resulting loss in weight to necessitate a discontinuance of 
nursing. Thus there may be a high fat — from 5 to 6 per cent. ; or very 
low fat — from 1 to 1.5 per cent. In the high-fat cases there is usually 
diarrhea with green, watery stools. The child strains a great deal and 
there are green stains on many of the napkins. In high-fat cases there 
is also regurgitation or vomiting of sour material. The fat-globules 
may readih^ be made out if the vomited material is placed under a low- 
power microscope. Low fat means deficient nourishment and may 
cause constipation. Sugar is rarely a cause of trouble in nursing 
babies. It seldom varies, ranging from 5 to 7 per cent, in the great 
majority of breast-milks. Young children, further, have a marked 
toleration for sugar. Protein constitutes one of the most important 
constituents of mother's milk. Like the fat, the proteid may be so 
decreased that nutritional disorder may be induced in the patient, or it 
may be very much increased, the latter condition being usually the 
cause of colic or constipation in otherwise healthy nursing infants. 
The milk may contain the normal percentage of fat, sugar, and proteid, 
but be scanty in amount. Instead of the four or five ounces to which 
the child is entitled, he may get but one or two ounces. Whether or 
not the quantity is sufficient, may be determined by weighing the baby 
before and after each nursing for twenty-four hours. One ounce of 
breast-milk weighs practically one ounce avoirdupois. The quality or 
strength is determined by an examination of the milk itself (p. 32). 
The quantity is determined by noting the weight of the child, wearing 
the same clothing, before and after nursing. By nursing for fifteen 
minutes, a child under four v/eeks of age should gain from 2 to 3 ounces ; 
four to eight weeks of age, 3 to 4 ounces; eight to sixteen weeks of age, 
4 to 5 ounces; sixteen to twenty-four weeks of age, 5 to 6 ounces; six to 
nine months of age, 6 to 8 ounces; nine to twelve months of age, 8 to 9 
ounces. Of course, arbitrary limits cannot be fixed as to the quantity. 

Stationary weight or loss in weight, with a dissatisfied child, usually 
means defects in quantity of milk, which are readily proved by the 
weighing. To be fed at the breast may also cause the child to suffer 
from an excess of good milk, in which event there will be vomiting or 
regurgitation, usually associated with colic. When this overfeeding 
continues, dilatation of the stomach develops, vomiting becomes habit- 
ual, the child loses in weight, the breast-milk is said not to agree, and 
often, unfortunately, the baby is w^eaned. This has been the outcome 
in scores of cases. When there is habitual vomiting and colic in a 
nursing baby, two things are to be done — the baby must be weighed 
before and after nursing, and the milk must be examined. 

I have repeatedly treated children for indigestion who were entirely 
relieved by shortening the nursing period. Weighing the baby at 
intervals of from three to five minutes and noting the gain has shown 
that the three or four ounces which may represent the child's stomach 
capacity were obtained in two, three, or five minutes, the excess which 
the child took over this amount being the cause of his trouble. From 
a free, full breast a vigorous nurser will take one ounce in one minute. 



28 THE PRACTICE OF PEDIATRICS 

When the nursmg "gait" is estabhshed, a child should be kept up to 
the schedule. There are few more pernicious teachings than that a 
baby should be allowed to nurse when he wants to and as long as he 
wants to. The idea that a nursing infant will take no more than is 
good for him is the fruit of inexperience. Recently a mother consulted 
me in regard to giving her one-month-old baby the bottle, as he had 
many green stools, cried a great part of his waking hours, and weighed 
but a few ounces more than at birth. Her milk was supposed to be 
''too strong" for the child. An examination of the breast and a talk 
with the mother satisfied me that the breast-milk was not at fault. 
An examination of the milk proved it to be good average milk, con- 
taining 3.5 per cent, fat, 6 per cent, sugar, 1.45 per cent, proteid. A 
one day's test by weighing was instituted. The infant was allowed to 
nurse one minute and rest one minute. During the resting period he 
was weighed. In this way, it was found that in three minutes he 
got from 3 to 3H ounces of milk. The nursing was then reduced to 
three minutes on one breast and five minutes on the other, which was 
the "slower" breast. Thereupon every sign of indigestion promptly 
disappeared, the stools became normal, and the infant made a satis- 
factory gain in weight of one ounce daily. 

The quantity may be suitable for the age, the child may not vomit 
or show a sign of indigestion, and yet may not thrive. In such a case 
an examination or repeated examinations of the milk at intervals of 
two or three days will usually show that it is poor, below the normal 
perhaps in both fat and proteid. 

Signs of Insufficient Nursing. — The baby remains long at the 
breast, perhaps one-half to three-quarters of an hour. When removed, 
he is restless and uncomfortable. After a short time, in an hour or less, 
he is very hungry and demands frequent nursings day and night. 

Management of Abnormal Milk Conditions. — When it is found 
that the breast-milk is too strong or too weak, or when the normal 
ratios of fat, sugar, and proteid are not maintained, it may be possible 
to increase or diminish the milk strength. When desirable, it may 
also be possible to increase either the fat or the proteid. The heavy 
milk will usually be found in mothers who are robust, who eat heartily, 
and who take but little exercise. In such a case, the prescribing of a 
plain diet, allowing red meat but once a day, discontinuing the malt 
liquors or wine, — which it will often be found that the mother is taking, 
— and directing that she walk a mile or two a day, will frequently 
bring the milk to digestible proportions. In some cases, however, this 
will not be successful, and the colic, constipation, and vomiting may 
continue, even though the quantity obtained at each nursing is within 
normal limits. In some instances it will be impossible to change the 
mode of the mother's life, except perhaps in the discontinuance of al- 
cohol. When such conditions prevail, the mother's milk may be modi- 
fied by giving from one-half to one ounce of boiled water or plain bar- 
ley-water before each nursing. This is a procedure to which I fre- 
quently resort. One teaspoonful of lime-water added to one ounce of 



I 



MATERNAL NURSING 29 

water before each nursing has made the breast-milk agree when other- 
wise breast-feeding would have been impossible. When the milk is 
deficient both in fat and proteid, a diet composed largely of red meat, 
poultry, fish, rj^e bread, or whole-wheat bread, oatmeal, cornmeal, 
with two or three pints of milk daily, will often be followed by an 
increase both in fat and proteid. The use of alcohol in moderate 
amounts, in the form of malt liquors or wine, will usually increase the 
fat. I have frequently seen it advance 2 per cent, in from two to three 
days. Disappointments in improving the quantity or quality of the 
breast-milk, however, are frequent. 

In addition to the one bottle which, for reasons above mentioned, 
is given early in the child 's life, I find it necessary at the seventh month 
to add an extra bottle or two. Usually at this time the proteid in 
human milk begins to diminish in quantity, and as this is the most 
important nutritional element, an insufficient quantity at this rapidly 
growing period of life is of no little importance. At the twelfth 
month, with very few exceptions, my nursing babies are weaned from 
necessity. At this age exclusive breast-nursing, if one would consider 
the best interests of the child, is practically out of the question. Out of 
many thousands of cases I recall but one instance where a mother was 
able successfully to nurse her child after the twelfth month. This 
remarkable woman, a mother of six children, had nursed every one of 
them exclusively up to the fifteenth or the eighteenth month. 

Mixed Feeding. — With a diminution in the amount of milk secreted, 
the breast-milk must, of course, be supplemented by modified cow's 
milk. This method of feeding is usually successful. If the mother of 
a four-months '-old baby can satisfactorily nurse him three times in 
twenty-four hours, he may be given, in addition, two or three bottle- 
feedings, supplementing the mother's milk. It is best, when using 
mixed feedings to alternate the breast and the bottle. The modified 
milk strength should be that which is suitable for the average child of 
the same age. (See Infant-Feeding, p. 58.) In beginning the use of 
cow's milk, however, it must be remembered that at first a weaker 
strength must be used than the child will require for growth, this 
weaker food being necessary in order gradually to accustom the infant 
to the change. If too strong a cow's-milk mixture is given at first, it 
will be very apt to disagree, causing colic and vomiting. Later, when 
the child has become accustomed to the new food, a stronger mixture 
may be given. When a mother cannot give her infant at least two 
satisfactory breast-feedings daily, it is advisable to wean the child. 
In infants under three months of age, it may be advisable to supple- 
ment the individual nursings. If the child requires four ounces at a 
feeding, and if we find by several weighings before and after nursings, 
that the breast capacity is but two ounces, an additional two ounces 
may be given by the bottle at the completion of the nursings. Follow- 
ing out this scheme I have been able to establish entire breast feedings. 

Maternal Conditions Under Which Nursing is Forbidden. — When 
the mother has tuberculosis in any of its various forms or manif esta- 



30 THE PRACTICE OF PEDIATRICS 

tions, whether it involves the glands, the joints, or the lungs, breast- 
feeding is to be forbidden. In epilepsy and syphilis nursing is likewise 
forbidden. In nephritis and malignant disease of any nature, and in 
chorea, nursing should be discontinued. Women who are rapidly 
losing weight should not be allowed to continue nursing their infants. 
In case of serious illness of any nature, such as typhoid fever, pneu- 
monia, or diphtheria, and upon the advent of pregnancy, nursing 
should be terminated. 

Care of the Breasts during Weaning. — When the breast-feeding 
is carried on the usual length of time, — from nine to twelve months, — 
the process of weaning ordinarily causes little or no discomfort. All 
that is usually required is to press out enough of the milk to relieve 
the patient as often as the breast becomes painful, which may not be 
more than two or three times a day. When the weaning is necessarily 
abrupt, no little discomfort may result. If there is a free flow of milk, 
which is apt to be the case when the weaning must take place in the 
early nursing period, tightly bandaging the breasts is required. When 
localized hardened areas occur in the glands, they should be massaged 
until softened, and the bandage reapplied and worn until the secretion 
ceases. When the weaning can be accomplished more gradually, the 
infant should have one less nursing every second or third day until 
only two are given daily. After this has been practised for one week, 
nursing can be discontinued. In cases where sudden weaning is re- 
quired, a saline laxative, such as citrate of magnesia or Rochelle salts, 
should be given every day for five days — sufficient to produce two or 
three watery evacuations daily. In the meantime the mother should 
abstain from fluids of all kinds up to the point of positive discomfort. 

Conditions Which may Temporarily Produce an Unfavorable 
Efifect upon the Breast-milk, but not Necessitate the Discontinuance 
of Nursing. — The advent of the first menstruation period particularly, 
and in some cases the beginning of every menstruation period, is at- 
tended with an attack of colic or indigestion in the child. Such at- 
tacks, however, rarely necessitate the discontinuance of the nursing 
even for a single day. 

Factors influencing the mental condition of the mother, such as 
anger, fright, worry, shock, distress, sorrow, or the witnessing of an 
accident, may affect the milk secretion sufficiently to cause no 
little discomfort to the child, and oftentimes the lessening of the 
flow for a day or two. The influence of the mother's mental state 
upon the character of the milk was early brought to my attention while 
I was resident physician at the County Branch of the New York 
Infant Asylum. In this institution there were usually about two hun- 
dred nursing mothers, the majority of them from the lower walks of 
life, at least 95 per cent, of the infants being illegitimate. The neces- 
sity of placing a considerable number of these mothers in wards, in 
close social contact, gave rise to rather frequent disputes, and not 
infrequently to fistic encounters of a decidedly vigorous character. 
After a particularly active disturbance, several nursing infants in the 



HUMAN MILK 



31 



ward would become suddenly ill, usually with vomiting, diarrhea, and 
fever. We soon learned to know the cause when inquiry or hasty 
inspection showed that the mothers of those who were ill had been 
particularly active in the dispute. A small proportion of the mothers 
were from the better walks of life. Letters of forgiveness or reproach 
or visits of a like nature from fathers, mothers, or sisters, have brought 
many a sick baby to my attention and caused me many anxious 
moments. 

Conditions Which Call for Temporary Discontinuance of Nursing. — 
During an acute illness with fever, such as indigestion, tonsillitis, and 
minor illnesses of a like nature, nursing should be discontinued for a day 
or two. During this period it should be our effort to maintain the flow 
of the milk. This is best done by emptying the breast with a breast- 
pump at the usual nursing period until the time arrives when the 
nursing may be resumed. In 
such conditions the advantage 
of having the baby accustomed 
to one bottle a day will at once 
be appreciated. 

Care of the Nipples. — Six 
hours after delivery or confine- 
ment the nipples should be 
washed with a saturated solu- 
tion of boric acid and the child 
put to the breast and nursing 
attempted. After this, the at- 
tempts at nursing should be re- 
peated every four hours, 
although the milk does not 
appear in the breasts until from 
forty-eight to seventy- two 
hours after the birth of the 
child. Colostrum may be pres- 
ent. It is useful as a laxative and may satisfy the child. A further 
advantage of the nursing at this time is that it gradually accustoms 
both the infant and the nipple to what will be required later. Imme- 
diately after the nursing the nipple should be carefully washed with 
a saturated solution of boric acid and thoroughly but gently dried. 
A baby should never be allowed to nurse from a cracked or fissured 
nipple. For this very painful condition a nipple-shield (Fig. 1) should 
always be used. 

HUMAN MILK 

While human milk varies as to the proportion of its nutritional 
elements at different periods of lactation, and even at different times of 
the day, milks upon which infants thrive agree within certain limits, 
so that a standard of limitations may be laid down. Among a great 
many specimens which I have examined the solids have ranged between 




Fig. 1. — Nipple-shield. 



32 THE PRACTICE OF PEDIATRICS 

12 and 13 per cent. The range in fat has been from 2.75 to 4.65 per 
cent., proteid from 0.9 to 1.8 per cent., sugar from 5.50 to 7.3 per cent. 
These figures represent the analyses of the breast-milks given children 
who were thriving and who were of different ages. The variations 
are not as wide as have been reported by others, but it is to be remem- 
bered that all these babies were thriving. Whoever has examined 
breast-milk even a few times is aware of the existence of the widest 
possible variations. I have seen breast-milks which contained 8 per 
cent, of fat and others which contained only 0.5 per cent.; but chil- 
dren thus fed were not well. Fat exists in mother's milk as minute 
globules in emulsion, varying somewhat in composition, depending 
upon the kind of food eaten. 

The proteids of breast-milk offer a wide field for further study. 
There are several of these proteids, the most important being casein 
and lactalbumin. The proportions are subject to considerable varia- 
tion, depending upon the diet and habits of life of the producer. With 
a continuation of lactation there is a diminution of the proteid, so that 
at the ninth or tenth month it is considerably reduced, the total 
proteid often being not over 1 per cent. The sugar content varies 
less than does either the fat or proteid, its range of limitation, even 
in milk otherwise poor, being not over 1.5 or 2 per cent. 

Directions for nursing well children will be found on page 26. 

Whether or not the child is getting a sufiicient'quantity of milk may 
be determined by weighing the baby before and after nursing. For this 
purpose the scales used for weighing children should weigh accurately 
in one-half ounces. The child, who need not be undressed, should be 
weighed when put to the breast and weighed at the completion of the 
nursing. I have repeatedly found that children who should get three 
ounces or more at a feeding, during the fifteen-minute nursings had in- 
creased in weight but one-half or one ounce, showing that only so 
much milk had been taken. Occasionally cases have been seen where 
there was no gain whatever after nursing and yet the child was sup- 
posed to have been fed. In the event of difficult breast-feeding it is 
well for the physician personally to supervise a nursing or two, for by 
this means much valuable information may be gained. 

Examination of Human Milk. — Milk of the mother is usually ex- 
amined to determine whether it contains a sufficient amount of fat, 
sugar, and proteid to nourish the infant; or to determine whether the 
quantity of one or more of the nutritional factors is excessive or deficient. 
Microscopic examination shows us little except the presence of colostrum, 
which usually disappears about the ninth day and is to be considered 
abnormal if present after the twelfth day. The presence of blood and 
pus may also be detected by the microscope. For an accurate analysis 
the milk should be sent to a laboratory properly equipped for such work. 
For absolute accuracy it is not safe to judge from the analysis of one 
specimen of milk; at least two, better three, specimens should be 
analyzed before coming to a conclusion. In collecting milk for exami- 
nation the middle of a nursing should be selected. 



THE WET-NURSE 33 



THE WET-NURSE 



We are called upon to select a wet-nurse under various conditions. 
A few families, particularly those who have had disastrous feeding ex- 
periences, ask that no attempts at artificial feeding be made, but that 
a wet-nurse be engaged in advance of the confinement so as to be 
ready when the time for her service arrives. Usually, however, our 
minds and those of the parents turn to the wet-nurse when nutrition 
by other means is a failure. It is well to remember in this connection 
that it is not wise to postpone our resort to the wet-nurse until every 
chance for her being of assistance has passed. I may take a few 
days' observation or but a single glance at one of these difficult 
feeding cases to decide whether a wet-nurse must be secured. Cer- 
tain it is that in a few cases we cannot do" without such aid. I see per- 
haps two or three cases a year, usually in consultation, in which I insist 
that further attempts at artificial feeding be discontinued because of 
the reduced condition of the patient. 

In the selection of a wet-nurse the age during which nursing is 
most successfully carried on is to be remembered. As a rule, a wet- 
nurse should not be under twenty-two or over thirty-five years of age. 
The peasant women of the continent of Europe make the best wet- 
nurses. A woman should not be selected as a wet-nurse without a 
thorough examination both of herself and of her infant, including the 
Wassermann test for syphilis. She must be free from skin diseases, 
tuberculosis, and syphilis. Whether she is stout or thin, tall or short, 
amounts to little. Neither can we place much reliance on the size of 
her breasts. Although full, firm breasts and prominent nipples are 
desirable, the best indication as to her nursing ability is the condition 
of her baby. For this reason it is best not to select a woman before 
her baby is four weeks old, for by that time his physical condition will 
indicate with considerable accuracy the kind of food he has been 
getting. The wet-nurse's milk need not correspond with the age of 
the patient for whom she is engaged, as breast-milk from the fourth 
week to the third month of lactation will answer for any infant. 

The results attending the first few days of wet-nursing are often 
most disappointing. The radical change which takes place in the 
nurse's habits of life, necessitating the leaving of her own child to the 
care of others, sometimes produces nervous conditions which may have 
a decidedly unfavorable influence upon her milk. Before arriving at 
the conclusion that she will not answer in a given case, she should there- 
fore have time to adjust herself to the changed conditions. Many a 
good wet-nurse, accustomed to a very plain diet and some work, which 
necessarily means exercise, has been ruined, so far as her usefulness as 
a milk-producer is concerned, by overindulgence at the table. Upon 
assuming her new office she is temporarily the most important member 
of the household, next to the baby, and articles of food are supplied to 
which she is entirely unaccustomed and of which she eats plentifully. 
The result is an attack of indigestion with fever, the baby is made ill, 
3 



34 THE PRACTICE OF PEDIATRICS 

and the usefulness of the wet-nurse in the family ceases. These women 
usually do best upon a plain diet of meat, poultry, fish, vegetables, 
cereals, and milk. If they are accustomed to taking beer, one bottle 
daily may be permitted. Coffee may be allowed to the extent of one cup 
daily, and of tea not more than two cups should be allowed. Women 
of this class are almost invariably neglectful of the bowel function, so 
that this must be attended to. One free evacuation should take place 
daily. As a rule, the wet-nurse has been accustomed to work and 
will be more contented and happy when her time is occupied. If she 
possess sufficient intelligence to take the baby for outings, she should 
be allowed to do so. Being out-of-doors from three to four hours a 
day is of decided advantage to every nursing woman. For the com- 
fort of the family it is wise not to let a wet-nurse know her full value. 
When she feels that she is • indispensable, trouble is apt to follow. 
It is particularly necessary, therefore, that babies who are wet-nursed 
should be given one bottle-feeding daily as soon as they are able to 
take care of it. The wet-nurse will then realize that she can be dis- 
pensed with in case of misconduct, or if she leave with an hour's 
notice the child can be given the bottle until another nurse is secured. 
In the great majority of my cases it has not been necessary to continue 
the wet-nursing after the children are seven months of age, for by this 
time they can usually be fed on the bottle. Of course, unless her 
nursing proves unsatisfactory, a wet-nurse should not be dismissed 
at the commencement of or during the summer. 

THE BREAST 

Cracked and Fissured Nipples. — Fissures of the nipples often re- 
sult from lack of care and cleanliness. Nipples that are not washed and 
dried, but allowed to remain moist after nursing, particularly during 
the first few days, are also very apt to become macerated and cracked. 
In the cases in which there is a tendency for the breasts to '^eak, " the 
milk decomposes on the nipples, and the nipple becomes actually ex- 
coriated by the acids formed by the decomposition in the milk. Leak- 
ing nipples should be kept covered with pads of sterile absorbent gauze. 
Cracks and fissures in the nipple may be sufficiently painful to pre- 
vent a continuance of the nursing. In getting the histories of not a 
few bottle babies, I have been told that nursing had been stopped be- 
cause of cracked nipples. The prevention and successful treatment 
of the condition, therefore, is a matter of no little importance. A 
strong child tugging on a fissured nipple may occasion excruciating 
pain to the mother, and when the fissures are not healed, it can readily 
be understood that such pain and the dread of nursing may produce 
sufficient mental distress to change the character or stop the flow of 
the milk, either of which conditions may require that the nursing be 
discontinued. 

Treatment. — The treatment which gives the best results, and which 
is used at the New York Nursery and Child's Hospital, is to bathe 
the parts with a saturated solution of boric acid after each nursing, 



THE BREAST 35 

dry the nipple, and apply a pad of sterile gauze. Once or twice a day 
the cracks or fissures are painted with an 8 per cent, solution of silver 
nitrate. There is no pain attending this application. The pad of 
sterile gauze just referred to is placed over the nipple and held in posi- 
tion by a binder sufficiently tight to support the breasts. Before the 
nursing the nipple is bathed with sterile water and the infant takes 
the breast as usual. If there are deep fissures, it may be well for a day 
or two to use a nipple-shield (Fig. 1). Another important reason 
for a rapid healing is the danger of infecting the gland through the open 
nipple wound — the usual cause of mammary abscess. The use of an 
ointment on the nipples is not advised, for the reason that it is of little 
or no service, and in most cases ointments do actual harm because they 
soften the epithelium and make the nipple tender. Diminishing the 
number of nursings to three daily has been of use in some severe cases 
which were slow to response of treatment. Removing the child from 
the breast entirely is to be advised only under conditions of much ur- 
gency. The milk may be entirely lost as a result of protracted ab- 
sence of this stimulation to the breast. 




Fig. 2. — English breast-pump. 

Depressed Nipples. — Not an infrequent source of difficulty in the 
management of the nursing function in a primipara is depressed nipples. 
The child cannot get a sufficient hold to make suction possible. He 
thus fails to get the desired nutriment, and in consequence both the 
child and the mother become exhausted. When this is repeated a few 
times, the child is very apt to refuse to make any attempt at nursing. 
In such cases the use of the nipple-shield is often indispensable, until 
the nipple is sufficiently drawn out and developed for the child to get 
hold of. Preceding each nursing it is well to manipulate the nipple 
for a few minutes or to elongate it by the use of the breast-pump 
(Fig. 2), without using sufficient force to draw the milk. 

Caking of the Breasts. — So-called caking of the breasts is of very 
frequent occurrence during the first few days of nursing. The milk, 
when it appears in the breasts, is often secreted in large amount. A 
great deal more is supplied than the child, with his small stomach and 
usually indifferent nursing, is able to digest. The breasts should be 
watched very carefully during this time so as to guard against the 



36 THE PRACTICE OF PEDIATRICS 

possibility of the milk remaining undrawn. After the completion of 
the regular nursing, if a considerable amount of milk remains in the 
breasts, it should be drawn by the breast-pump (Fig. 2) and the breast 
thus relieved. 

Caking is frequently the outcome of fissured nipples. Sucking on 
the part of the child, the use of the breast-pump, and hard pressure in 
milking are all very painful procedures, with the result that the milk 
remains undrawn. 

Treatment. — When nodules form, they may readily be softened by 
gentle massage. Lanolin should be used on the fingers so as to avoid 
unnecessary irritation of the skin. The massage should be repeated as 
often as the nodules appear. The caking is more apt to occur in the 
dependent portion of the glands. The so-called pendulous breasts, 
which may show a tendency to cake, should be supported by a binder 
lightly applied. 

Acute and Suppurative Mastitis. — When inflammation of the 
breast develops with fever, chills, and prostration, it is usually the re- 
sult of an infection through the nipple, generally one with visible 
cracks and fissures. For our purposes the different varieties of 
mastitis need not be considered. Nursing from the involved breast 
should be discontinued, for the sake of both the child and the 
mother ; in fact, the pain is often so great that nursing is impossible. 
A supporting bandage should be applied and the milk drawn 
with the breast-pump at the usual nursing times. It must be 
our aim to induce resolution without the formation of pus. This 
is best accomplished by the use of an ice-bag which is applied 
to the inflamed, indurated area. If there is a tendency to 
constipation, saline laxatives should be used. In fact, the patient will 
often be benefited not a little by two or three watery evacuations daily. 
With a subsidence of the temperature and an abatement of the inflam- 
mation, nursing may be resumed. As soon as the presence of pus is 
determined, it should be removed regardless of its location in the gland. 
I have seen cases of intestinal infection in the infant and of infectious 
processes in other parts of the body, that were imdoubtedly due to 
nursing from suppurating breasts. 

THE NURSERY 

The nursery should be the largest and best ventilated room in the 
house. In a city home the room may well be located on the third or 
fourth floor, with a southern exposure. In apartments, quiet and the 
possibility of free ventilation and sunlight must be considered in 
selecting the room. For the sake of quiet, the nursery should not 
communicate with the sleeping-rooms of older children. 

In placing children in sleeping-rooms or in a nursery, or in estimating 
the capacity of hospital wards for children, it is to be remembered that 
at least one thousand cubic feet of air-space should be allowed to each 
child. 

The floor of the nursery should not be carpeted. A hard-wood 



THE NURSERY 37 

floor is best. If this is not possible, covering the floor with oil-cloth 
or linoleum is always possible. This can be cleaned with a damp cloth 
every day. A broom should never be used in a nursery. Paint or 
hard finish on the walls is preferable to paper. There should be at 
least two windows and an open fireplace. If possible, the bath-room 
should be connected with the nursery, to be used not only for bathing 
the child but as a ''changing room." The child 's napkins should not be 
changed in its living-room if it can be avoided. It is needless to say 
that napkins should never be dried in the nursery. 

Steam heat as ordinarily used today is the least desirable means 
of heating, on account of its uncertainty. In many New York apart- 
ments of the better class, the fires are banked at 10 p. m.; the tempera- 
ture when the child retires is perhaps 70°; by five or six o'clock in 
the morning a fall to 50° or 60°F. has taken place. Such a change 
in the temperature, with the tendency of children to kick off the 
bed-clothes, explains many cases of tonsillitis and bronchitis. The 
temperature of the nursery should be kept as even as possible. When 
for any reason this cannot be controlled, it is best to have two means of 
heating, so that when one fails the other may be used. The open grate 
fire or a small wood-stove is best. Gas should never be employed as 
a means of heating a child's sleeping-room, on account of the rapid 
exhaustion of the oxygen which results from its use. 

The furniture of the nursery should be of the plainest. Hard- wood 
chairs and tables with enamel or brass cribs or bedsteads should be 
used. There should be no arti cle of furniture or furnishings in a nursery, 
that cannot be washed. In the bath-room or in some room adjoining 
a pail should be kept containing some disinfectant solution, such as 
carbolic acid, 1 : 100, or carbonate of soda solution, 1 ounce to 2 gallons 
of water, in which the napkins are placed as soon as soiled. 

There should be two shades at each window, a light and a dark one, 
so that it will be possible to darken the room during the sleeping time, 
as well as to exclude the early morning light, which is the usual cause 
of too early waking. Babies should be taught to sleep until at least 6 
o 'clock in the morning. This is far better for the child and also for the 
mother if she occupies the same room. The unnecessary habit of an 
early waking at 4 or 5 o'clock will in most instances readily be broken 
by keeping the room dark. 

The nursery should have suitable means for ventilation. For this 
purpose, aside from the fireplace, I have found the window-board 
of no little service. It can be made of any width. Ordinarily, I have 
it made about six inches wide. It is sawed so as to fit tightly under 
the lower sash. This leaves an open space corresponding to the width 
of the board between the upper and lower sash, and allows the en- 
trance of a current of air which is directed upward. There should be a 
thermometer in every child's living-room or nursery. It should reg- 
ister from 70° to 72°F. by day and from 60° to 65°F. by night. The 
nursery should be given an hour's airing twice a day. The child 
should sleep in a crib, alone, not with an adult or an older child. 



38 THE PRACTICE OF PEDIATRICS 

The old-fashioned cradle in which generations have been rocked may be 
an interesting heirloom, but under no circumstances should it be re- 
moved from its place in the garret. It is realized that the above sug- 
gestions are not applicable in many homes. Nevertheless, if we aim at 
the ideal, existing conditions, no matter how unpromising, will in- 
variably be made better. 

THE NURSERY MAID 

In certain stations and conditions of society the young child is 
cared for by the mother with the assistance of the immediate members 
of the family. In thousands of homes, however, a helper is employed 
to take charge of the child or assist in its care. The selection of a 
nursery maid is a matter of much importance. Schools for training 
nursery maids exist in New York City, Boston, Albany, Newark (New 
Jersey), and doubtless in other cities. Although such trained help is 
greatly to be desired, the supply is very limited. Some of my best 
children's attendants have been women who, although they have not 
passed the meridian of life, still have reached the seasoned age when 
the attractive qualities of policemen and grocery boys have faded into 
a dim recollection. Any industrious, sensible young woman of quiet 
tastes who is fond of children can be trained in a few weeks into a most 
useful helper. The association of the nursery maid and child is a close 
one, and it is the physician's duty to know that the applicant is phys- 
ically fit for the position. 

During a single year the writer has known of three nursery maids who 
developed pulmonary tuberculosis while in service. Not only should 
the applicant's lungs be examined, but also the mouth, nose, and throat. 
Carious teeth and diseased conditions of the throat and nose should 
receive careful attention before the maid is allowed to assume the 
position. It is also important that something of the applicant's pre- 
vious life should be known. 

One of the most important things to know about an applicant in a 
large city, and one most difficult for the physician to discover, is the 
existence of leukorrhea, or vaginal discharge.* This, however, can 
usually be discovered by the tactful young mother. Not only should 
the ideal nursery maid be physically fit, she must be mentally fit as well. 
For proper mental and physical development, children must be enter- 
tained and pleasantly employed. An ill-natured, impatient nurse 
should be forced to seek other employment. It should not be a task 
for a child's attendant to play with him. A woman should not be con- 
demned, however, because she fails with any given child. With a child 
differently situated, with a different temperament, the results may be 
perfectly satisfactory. 

WEIGHT 

The average weight of the full-term, newly born infant varies from 
six to nine pounds. Some are born at term weighing less than six 

* A very severe gonorrhea was contracted by one of my patients from a nursery 
maid. 



WEIGHT 39 

pounds and a few weighing over nine pounds, but in the great majority 
the birth- weight will be found between these figures. Holt found from 
a study of the records of three large maternity institutions in New 
York City as follows: 

The average weight of 568 females was 7.16 pounds. 

The average weight of 590 males was 7.55 pounds. 

Every family which can afford it should have a scale (p. 41) for 
weighing the baby, for only by regular weighing during infancy and 
childhood can we gain an accurate knowledge of growth. During the 
first five days of life there is usually a loss in weight of four to six ounces. 
After this initial loss, which may be expected but which does not always 
occur, a weekly gain in weight is to be looked for, the child regaining 
the birth- weight on the eighth or tenth day. At first it is advisable to 
weigh twice a week, or even daily, if the child is not progressing satis- 
factorily. After the second month, when the infant is making satis- 
factory progress, a weekly weighing will answer, and this should be 
continued until the child is one year of age. During the second year, 
bi-monthly weighings are sufficient. Girls of the same age, after the 
first year, will average from one-half to one pound lighter than boys. 
During the third year, monthly weighings will be sufficient to enable 
one to keep in touch with the child's condition. During the first six 
months of life a weekly gain of four to eight ounces has been made by 
the well children under my care. When a child does not make at least 
an average gain of four ounces weekly, I do not put him in the '' doing 
well" class, but look into his care and nutrition to learn what is wrong. 
Children vary in growing capacity. Some will increase in weight rap- 
idly, gaining three ounces a day, while others will make a slower gain 
and yet be perfectly well. Through the care of many children, I have 
come to regard four ounces as the minimum weekly gain for a well child. 
In a well infant the birth-weight should be doubled by the fifth or the 
sixth month, and at one year the weight should be a little over two and 
one-half times that at birth. During the second year a gain of five 
and one-half to seven pounds will usually result under proper condi- 
tions. During the third year from five to six pounds will be added. 
At the fifth year the weight should be in the neighborhood of forty-one 
pounds. It is not to be inferred that these are arbitrary figures or that 
perfectly well children may not be under or above the figures given at 
the ages mentioned. These figures are, however, to be regarded as 
the average for the different ages. 

A weight chart with its colored "normal" line will not be found in 
this book, and physicians are advised against its use. Time and again I 
have seen well infants, though slow in growth, made ill by overfeeding, 
in the vain attempts of an ambitious mother or nurse to keep her in- 
fant up to the "normal" line. 

The weighing alone is not sufficient to inform us absolutely con- 
cerning the development of children. I have seen babies who showed 
a most satisfactory weight curve, yet who, on examination, were by no 
means up to the requirements for their age as regards their bone and 



40 THE PRACTICE OF PEDIATRICS 

muscle development. A nursing or bottle baby should be examined 
once a month in order to determine if the progress is along the desired 
lines as shown by the condition of the teeth, the fontanels, the long 
bones, and the muscles. 

The following table from Holt's ''Diseases of Infancy and Child- 
hood" gives the weight and height of children from birth to the six- 
teenth year. The weights under five years are taken without clothing. 
After the fifth year the weight of the clothing is to be deducted. The 
average weight of house-clothing, according to Holt, who quotes Bow- 
ditch, is at the fifth year 2.8 pounds for both sexes; at the seventh year, 
3.5 pounds for both sexes; at the tenth year, 5.7 pounds for boys and 
4.5 pounds for girls; at the thirteenth year, 7.4 pounds for boys and 5.6 
pounds for girls; at the sixteenth year, 9.7 pounds for boys and 8.1 
for girls. These weights must be deducted from the gross weights in 
order to obtain the net weights of the children. The season of the year, 
of course, would make some difference in the weight of the clothing, 
although this point is not mentioned by the observers. 



Age. Sex. 



Weight, Height, 
Pounds. Inches. 



Birth /^^y^ 7-^^ 20.6 

^^^*^ 1 Girls 7.16 20.5 

« .. /Boys 16.0 25.4 

^ "^°^*h« • • • i Girls 15.5 25.0 

/Boys 21.0 29.0 

1 Girls 20.5 28.7 

/Boys 24.0 30.0 

1 Girls 23.5 29.7 

"^ y^^"^^ 1 Girls 26.0 32.5 

Boys 32.0 35.0 

Girls 31.0 35.0 



12 months, 
18 months. 



3 vears. 



4 years ^ g^^^ ^^-^ ^^"^ 

^^^^^^ \ Girls ....35.0 38.0 

rehears / ^^^^ ^^-^ 41.7 

^ y^^^^ t Girls 39.8 41.4 

Shears / ^^^^ • ^^^ ^^-^ 

^ ^^^"^^ 1 Girls 43.8 43.6 

^ y®^^^ \ Girls 48.0 45.9 

^ y^^^^ \ Girls 52.9 48.0 

Q„__ /Bovs 60.0 50.1 

^ y^^^^ 1 Girls 57.5 49.6 

in,..o.o /Boys 66.6 52.2 

10y^^^« IGirls 64.1 51.8 

11 vears I ^^^^ '^2. 4 54.0 

^^ y^^^^ t Girls 70.3 53.8 

^^y^^""^ i Girls 81.4 57.1 

T^ _ /Boys ... 88.3 58.2 

13 years ^qj4 9^2 58.7 

.. /Boys 99.3 61.0 

14 y^^'^ i Girls 100.3 60.3 

1^ /Boys 110.8 63.0 

1^ y^^'^ i Girls 108.4 61.4 

16 vears ^ ^^^^ 123.7 65.6 

1^ y^^^^ \ Girls 113.0 61.7 

The above table allows of considerable latitude and with the child 



THE CARE OF THE STUMP OF THE UMBILICAL CORD 41 

remaining within the normal. A boy patient who represented most 
rapid growth measured 69% inches when 12 years of age. 

Scales. —A scale for weighing the baby is a very necessary adjunct 
to the nursery furnishings. There are several varieties of scales on the 
market known as ''baby scales." Their usual construction provides 
for a basket for holding the baby, the basket being supported by a steel 
rod which rests upon a spring. A needle indicates on a dial the weight 
of the child. This variety of scale is very unsatisfactory : it gets out of 
order easily, it is expensive, and with a vigorous, kicking child, the rapid 
oscillation of the needle makes an accurate reading of the weight dif- 
ficult if not impossible. Further, the weight capacity of these scales 
is but twenty pounds. When the child's weight reaches this figure, 
it necessitates the purchase of another scale. The scoop and platform 
scales used by grocers are best. They do not easily get out of order, 
they weigh correctly from one-half ounce to two hundred and eighty 
pounds, and being very simple in construction, they can readily be 
understood. The infant rests on his back in the scoop during the 
weighing process; older children stand on the platform. 

HEIGHT 

The length or height of children at the various ages is for conven- 
ience included in the weight table. From the standpoint of health or 
development, height is of no great significance. The length at birth 
usually varies from 19>^ to 21 inches. Children suffering from tardy 
malnutrition, particularly if syphilitic, may be undersized. Not a few 
of the non-specific malnutrition and anemic children are tall and thin. 
It is often a matter of no little distress to parents that their children 
are undersized. Short mothers and fathers cannot expect very tall 
children. If the latter have right care, they will probably be larger 
than the parents, but cannot be expected to grow as much as play- 
mates whose fathers and mothers are tall. The height bears much less 
relation to the condition of the child than does the weight. 

THE CARE OF THE STUMP OF THE UMBILICAL CORD 

The space devoted to the care of the umbilical cord might seem out 
of place in a work of this nature. The excuse is the frequent appear- 
ance in private practice and in out-patient clinics of infants with 
umbilical polypi, granulomata, suppurating umbilical stumps, or 
eczema involving a considerable area about a moist, actively secreting 
umbilicus. The management of granuloma, polypus, and localized 
eczema about the umbilicus has been referred to elsewhere. In order 
to secure a rapid and complete cicatrization after the cord falls, it is 
essential that the parts be kept dry. I have used with gratifying 
success a powder composed as follows: 

I^ Pulveris acidi salicylic. gr- x 

Pulveris acidi borici gr. xxv 

Piilveris amyli 

Pulveris zinci oxidi aagss 



42 THE PRACTICE OF PEDIATRICS 

Over this powder, which is used freely in the open wound, is placed 
a retaining pad of gauze. The dressing should be changed and fresh 
powder applied every time the child is fed. For the small unhealthy 
granulations often present, cauterizing with a 50 per cent, nitrate of 
silver solution may be necessary once or twice, after which the powder 
should be used until the secretion has entirely ceased and cicatrization 
is complete. 

MENTAL AND PHYSICAL DEVELOPMENT IN THE INFANT 

Dr. Frederick Peterson,* of New York, has made an exhaustive 
study of the mental development of the newly born. 

In all, 1060 newly born infants were examined, the observations 
extending over one year. His observations, which are to be looked upon 
as authentic, are as follows : 

*' 1. Sight. — Sensibility to light is present in most' infants at birth, 
and this is the case even in those prematurely born. The optic nerve 
is, therefore, already prepared to receive impressions, sometimes even 
before the time of normal birth. 

^'2. Hearing. — Sensibility to sound is quite as apparent as sensi- 
bility to light at birth, for 276 normal white children reacted to sound 
on the first day of life, and 146 reacted to light. A similar condition 
existed among the premature infants, many reacting to sound on the 
first day as well as to light. The auditory nerve is already prepared to 
receive impressions of sound sometimes before the period of normal 
birth. This is wholly contrary to the opinions of other authorities. 

" 3. Taste. — The gustatory nerve not only reacts differently to salt, 
sweet, bitter, and sour at birth, but the same mimetic reactions are 
observed in premature infants. This nerve is, therefore, ready to re- 
ceive taste impressions some time before the normal period of birth. 

"4. Smell. — Two hundred and seven normal white children reacted 
to odors on the first day of birth, and similar reactions were observed 
in premature infants. The olfactory nerve is ready to receive smell 
impressions some time before the end of the normal period of gestation. 

"5. Cutaneous Sensibility.— Reactions to touch and temperature 
and affective manifestations of discomfort, obtained the first day in 
large numbers of normal infants, were similarly obtained in premature 
infants, showing that such sensibility is already present before the ex- 
piration of the period of normal gestation. There is every reason to 
believe that sensitiveness to painful stimuli is present, but the reactions 
are more vague and uncertain than in later life, which leads many to 
assume that the sense of pain is dull in the new-born. Muscular sense 
cannot be tested in infants, but there is every reason to believe that 
muscular sense, the sense of motion, and sense of position are developed 
early in utero. 

"Q. Thirst-hunger and Organic Sensation. — The new-born child 
frequently reacts to thirst-hunger on the first day, though the actual 
* Bulletin, Lying-in Hospital, December, 1910. 



MENTAL AND PHYSICAL DEVELOPMENT IN THE INFANT 43 

need of food is seldom apparent until after the first or second day. 
Discomfort is clearly marked when nourishment is not forthcoming. 
The cries of discomfort and pain are marked in the first day in full- 
term infants and noteworthy in the premature. 

"7. The Beginning of Memory, Feeling and Consciousness in 
the New-born Child.^ — There are good grounds for believing that the 
new-born child comes to the world already with a small store of experi- 
ences and associated feelings and shadowy consciousness. The fact 
that even in premature infants we find the senses already prepared for 
the reception of impressions on the five senses is some evidence of such 
impressions having been already received and stored up in the dim 
storehouse of a memory already begun. It may even be that some sort 
of vague light impressions have been received, for it is possible that in 
the interior of the body the alternation of day and night may in a mild 
degree be manifested. The transillumination of the hands before a 
candle, of the skull and face bones by examination of the frontal sinuses 
and antrum with electric lights, are evidence of a certain amount of 
translucency of the whole organism to sunlight, which is so much more 
powerful than any artificial light. There is greater possibility in the 
matter of the auditory sense, that it may be stimulated by sounds 
within the body of the mother (by bone conduction possibly) — such 
sounds as the beats of the maternal and fetal hearts, the uterine and 
funic souffles, and the bruit of the maternal aorta. 

" Moderate stimulation of the gustatory nerve is thought to occur 
through the common swallowing of amniotic fluid by the fetus. 

" A marked development of receptivity in the senses of touch and of 
muscular sense during uterine life is undisputed. Movements begin 
considerably before the sixteenth week of pregnancy, and increase in 
character and extent from that time on. Often they are so violent as 
to be painful to the mother. The activity of the muscles and constant 
contact of various parts of the fetal body with the uterine walls for a 
period of months before birth must lay a foundation under the threshold 
of consciousness for a sense of equilibrium and vague spatial relations. 
The material basis of consciousness is prepared long before birth. 

'^ There is already a feeling tone associated with the earliest re- 
actions, though we are altogether in the dark as regards its psychophys- 
iology. The process has been thus formulated: Stimulus — reaction 
— liking — reinforcement. Stimulus — reaction — dislike or pain — in- 
hibition. This is the early simple associative memory in reactions 
to stimuli. 

"8. There are no perceptible differences in reactions of colored and 
white children or between pairs of twins. 

''Ability to hold the head erect: This may be acquired at the third 
month. Few infants, however, are able fully to support the head be- 
fore the fifth month. Not a few perfectly normal infants will not be 
able to support the head before the ninth month. 

''Sitting erect: The ability to sit erect unsupported is acquired be- 
tween the sixth and eighth months. 



44 THE PRACTICE OF PEDIATRICS 

'^ Standing: Many infants will stand with simply hand support at 
the tenth month. Exceptionally well-developed infants will stand 
with the hands resting on some object at the eighth month. A remark- 
able infant under my observation could stand at the fifth month, 
and walked alone at the eighth month. The average infant walks 
alone from the fourteenth to the sixteenth month. A few will be able 
to walk unsupported before this period, and other normal children will 
not walk alone before the eighteenth or. twentieth month. 

"Laughing: Many infants may be made to laugh from the third 
to the sixth week. 

'* Memory: The infant's memory is very short. I have repeatedly 
known infants eighteen months of age who have entirely forgotten the 
mother in a week. 

" Speech : Intelligible words are formed at about the twelfth month. 
From the eighteenth month to the second year two or three words will 
be intelligently put together." 

BASKETS FOR EARLY EXERCISES 

It is a mistake made in many families to have the baby in the arms 
a greater part of his waking hours. This practice should be dis- 
couraged by physicians, for when the child is held, there is always a 
tendency to make him sit upright on the arms or knee without proper 
support. During the early months of life the vertebrae and vertebral 
ligaments are not sufficiently developed to support the heavy head and 
trunk. If this thoughtlessness on the part of parents with its attend- 
ant dangers were explained, there would be fewer cases of displaced 
scapulae and spinal curvature to be treated later. Many cases of spinal 
curvature are the direct outcome of such early abuse of the spinal 
column. Still, it is not desirable that the (fhild should constantly 
occupy the crib. A large clothes-basket in which a thick blanket and 
pillow have been placed affords a safe playground for a small baby. 
For the first few months he will lie on his back and amuse himself in 
his own peculiar way. After the sixth month, when he may be allowed 
to sit up for a short time each day, a pillow should be placed behind 
his back for support. The basket supplies plenty of room for toys 
and other means of entertainment. When the child begins to stand 
and attempts to walk, the basket period is at an end and the exercise 
pen (p. 767) should be brought into use. 

CRYING 

It is well for the young infant to cry a little every day. Muscular 
movements involving a greater part of the body accompany the act 
of crying and furnish exercise. Peristalsis is increased, as is often evi- 
denced by a movement of the bowels occurring during crying, particu- 
larly when there is diarrhea. In crying, deep breathing is necessary, 
the lungs are expanded, and the blood oxygenated. The well baby 



SLEEP 45 

cries when frightened, or uncomfortable from hunger, soiled napkins, 
or inflamed buttocks. He cries from pain, from heat, from cold, from 
unsuitable clothing, and during difficult evacuation of the bowels. He 
also cries when displeased or angry. Authors are prone to refer to the 
diagnostic value of an infant's cry. It is my belief that characteristic 
cries are not to be depended upon sufficiently to give them a differential 
diagnostic dignity. Children slightly but painfully ill may cry inces- 
santly for an hour or two. Thus, with intestinal colic, the cry is 
loud and continuous until the child is relieved or falls asleep from 
exhaustion. Earache is not an infrequent cause. The habitual 
criers, the restless and vigorous, crying, whining infants, are uncom- 
fortable. With very few exceptions the trouble will be found in the 
intestinal tract. The well-trained, normal child, whose nourishment 
is suitable, is seldom troublesome. When well, all babies are natu- 
rally good-natured and happy in their own way. Badly managed, 
spoiled infants often cry vigorously when left alone. When attention 
is given them, when they are taken up and talked to, the crying ceases. 
This readily tells us that pain or discomfort was not an element in 
causing the cry. By these infants, discipline, not medication, is 
needed. The management of the habitual crier involves the relief of 
the condition which causes the discomfort, or the most rigid discipline, 
when it is demonstrated that we are dealing with a '' spoiled infant." 

SLEEP 

The infant who sleeps well is almost always a normal, well-fed baby. 
Irritability and sleeplessness are associated with indigestion more 
frequently than with any other disorder. During the first few days of 
life the sleep, in normal conditions, is almost unbroken, except when the 
infant is fed. During the first month the infant sleeps about twenty- 
two hours out of every twenty-four; during the second and third 
months, from twenty to twenty-two hours. At the sixth month the 
child should sleep from 6 p. m. to 6 a. m. without interruption except 
for feeding or nursing, which need cause very little disturbance. At 
this age there should be a two-hour nap during the morning and a two- 
hour nap in the afternoon, although it is not well to have the baby sleep 
after three o'clock in the afternoon. The twelve-hour night rest should 
be continued until the child is six years of age. The day naps will 
gradually be shortened by the child. At one year of age, one hour in 
the morning and two hours in the afternoon suffice. From the 
eighteenth month to the second year the morning nap is given up. 
Afternoon rest for at least one and one-half hours should be continued 
until the sixth year of age, and longer if the child is inclined to be 
delicate. Regular sleep is largely a matter of habit, and if the infant 
started right with suitable feedings given at definite times ^ followed by 
the proper period of sleep, but little trouble will be experienced. When 
sleep is disturbed and broken, it means bad habits, unsuitable food, 
minor forms of indigestion, or positive illness of some kind. Sleep is 



46 THE PRACTICE OF PEDIATRICS 

important for purposes of growth, not only in early infancy but 
throughout childhood. Not a few infants form habits of sleeping in 
the daytime and being wakeful at night. This is best remedied by 
keeping the baby awake during the day, by entertainment, and by 
keeping him in a well-lighted room. A proper amount of sleep is most 
essential to nutrition, and I am sure that the satisfactory results which 
I have had the good fortune to achieve in the treatment of secondary 
malnutrition and anemia have been due in part to my insistence that 
the child sleep in a quiet, darkened room for two hours after the noon- 
day meal. The energy expended in twelve hours by an active child 
is incalculable, and when a portion of this energy is reserved and the 
body fortified by rest and sleep during the middle of the day, there is a 
greatly diminished daily expenditure of strength units. 
For bathing newly born see p. 20. 

STOOLS 

Breast Fed Stools. — Infants on the breast average two to three large 
stools daily, although the number may range from one to five and 
still be consistent with perfect health. Their color is usually of a 
bright yellow or orange tint, and their character of a smooth and 
homogeneous consistency, with a slightly acid reaction. The odor is 
not as offensive as the cow's milk stool, as there is less putrefaction 
of the protein while in the intestinal tract. The bulk or residue 
corresponds to the amount of ingested food. 

Cow's Milk Stools.- — Infants on the bottle usually average only one 
stool a day, which oftentimes is smaller than that of the breast-fed 
baby. The color is lighter and the proportion of feces to the amount 
of food taken numerically less when artificially fed. 

Hard Constipated Stools. — A hard constipated stool, when not pro- 
duced by any mechanical cause, is usually due to a deficiency in the 
food of either carbohydrates or fats, generally the latter. Food too low 
in total solids, leaving an insufficient residue is also a cause. Irregular 
habits in the time of going to stool and a lack of systematic general 
training also play a part. Sterilization and, to a lesser degree, 
pasteurization, make milk somewhat constipating. 

Loose Watery Stools. — This type of stool is seen in indigestion, with 
fermentative changes in the carbohydrates of the food, and to a lesser 
extent of the fats. The stools vary in color from a yellow or yellowish 
brown to green. They are usually alkaline in reaction and have a 
foul, musty odor. Curds are seldom seen and there is very little 
mucus. 

StoolinHard Balls. — This variety of stool is usually due to an excess 
of fat in the food. The feces vary in color from a light yellow to a 
light grey. They are sometimes large and hard and at other times 
dry, small and crumbly. 

Scrambled Egg Stools. — Stools of this order are seen when the 
carbohydrate digestion is at fault. Bacterial fermentations of the 



THE NURSING-BOTTLE AND NIPPLE 



47 



starch, or sugar which is not assimilated by the organism gives rise 
to loose, green, frothy movements. These are very acid, frequently 
causing excoriations of the buttocks and surrounding parts. 

Mucus in Stools. — Mucus in stools denotes a form of irritMion in 
the digestive tract which gives rise to an excessive secretion from the 
mucous glands of the intestine. It is almost invariably present in 
abnormal stools. Mucus and feces intimately mixed indicates the 
source of the trouble to be in the small intestines; or if on the outside 
of a constipated stool, from the rectum; if in combination with a clay- 
colored stool, from the duodenum. 

Blood in Stools. — In older children, blood in- 
timately mixed with the stools would suggest an 
ulceration of the stomach or small intestine. When 
on the outside of a constipated stool, it may indicate 
a rectal lesion, an anal fissure, diverticuli, or in- 
complete intussusception. A stool composed of 
blood and mucus without fecal material is very 
characteristic of intussusception. Melsena neona- 
torum or hemorrhage of the newly-born is char- 
acterized by a profuse discharge of blood from the 
rectum. 

Curds in Stools. — This is one of the most frequent 
of the abnormal constituents of infant's stools. 
Two kinds are found : one firm and tough and very 
hard to press out, insoluble in ether, varying in size 
from a small pea to a hickory nut, with a brown or 
greenish coating, but white on cross-section, which 
is known as a protein curd; the other is composed 
of fat, easily pressed out, does not sink in water 
varies in color from white or yellow to green, is 
somewhat soluble in ether, and is not hardened by 
formalins. 





Fig. 3. — Nurse-bot- 
tle and nipple. 



THE NURSING-BOTTLE AND NIPPLE 

There are two requirements that a nursing- 
bottle must fulfil : it must have a capacity sufficient 
for one full feeding and it must be so constructed 
as to be readily cleansed. The oval bottle with 
rounded edges answers best. These may be ob- 
tained in sizes of from three to nine ounces. As many bottles are 
needed as there are feedings in twenty-four hours. The bottles should 
be boiled once a day, scrubbed with a stiff brush with hot borax water, 
and remain in the borax water until needed. Two teaspoonfuls of 
borax to a pint of water is the strength usually used. Before using, 
bottles should be rinsed in plain boiled water. The straight black 
nipple (Fig. 3) is also preferred, for the reason that it can be turned 
inside out and easily cleansed. A nipple which cannot be turned 
should never be used. After use, the nipple should be turned and 



48 THE PRACTICE OF PEDIATRICS 

scrubbed with a stiff brush and borax water — a tablespoonful of borax 
to a pint of water. When not in use, the nipple should be kept in 
borax water. Before being placed on the bottle, it should be rinsed in 
boiled water. The nipple should be boiled once a day. The blind 
nipples — those without holes — are the best. Holes of the required 
size may be made with a red-hot cambric needle. 

Substitute Breast-feeding; Artificial Feeding 

A considerable number of the young of the human race are de- 
prived of the natural means of nutrition, the milk of the mother. 
For comparatively few is a wet-nurse available. While in proportion 
to the children born more mothers are nursing their infants now than 
formerly, nevertheless every year thousands of infants are brought into 
the world who have to be nourished by other means than human milk. 
The fact that an immense number of deaths occur every year among 
these infants because of defective nutrition speaks for itself. 

Nutritional Errors. — Mortality statistics give a very inadequate 
idea as to the part played by nutritional errors in the young, for the 
reason that in many instances such errors are not the direct or perhaps 
the immediate cause of death, and for this reason their influence does 
not appear in mortality statistics. As elsewhere pointed out, and 
dwelt upon at length in this work, in disease of any nature a child's 
resistance is a factor of paramount importance. With defective 
nutrition, resistance is invariably below the normal. Many of the 
infants who die from the intestinal diseases of summer, from grip, from 
tuberculosis, or from infectious diseases, suffer from defective nutri- 
tion in different degrees of severity before the immediate cause of 
death exists. 

The Needs of the Patient Paramount. — As nutrition deals directly 
with questions of life and death, it is not surprising that volumes have 
been written on the subject, but it is surprising that the fundamental 
principles of infants' nutrition are so little understood. This is due in 
part to the fact that writers and teachers of infant-feeding, in their 
efforts to be scientific or ultra-scientific, have lost sight of the point' 
that there is a patient as well as a pupil to be considered, and that not a 
few teachers with their algebraic or otherwise intricate formulas do 
little but obstruct the progress of rational feeding by making a readily 
comprehended subject impossible to many. Another common error 
is in not distinguishing between children — the rich and the poor, the 
sick and the well. A child with malnutrition, with marasmus, or with 
a temporarily disordered digestion is by no means a well baby, and 
when he is given food suitable only for the well, his condition very 
naturally is not improved. 

Environment. — In feeding an infant, several predominant factors 
must be considered. The influences of environment are most important. 
The infant in a children's institution has to be fed differently from 
one who comes to a dispensary for treatment, and both must be fed 



COW^S MILK 49 

differently in summer than in winter. The child of well-to-do, intelli- 
gent parents is fed still differently. There are no hard and fast lines 
in infant feeding other than that there must be an ample supply of such 
nourishment as the child can digest and thrive upon. Cow's milk is 
used as the basis of infant's food, for the reason that it is ordinarily 
readily adapted to the child's digestion and is the most available 
substitute for human milk. 

Successful Substitute Feeding. — Successful substitute feeding of 
infants consists, then, in giving something upon which the child can 
live and thrive, and when, in addition, this ''something" supplies the 
nutrition which nature demands, it constitutes scientific infant-feeding, 
whatever the source of the nutriment. Cow's milk is just as fully an 
unnatural food for an infant as is barley or rice gruel or the milk of the 
goat or the ass; and cow's milk only is used, as already mentioned, 
because in a great majority of cases it answers the given purpose better 
than does any other food, in that it furnishes in an available form the 
nearest approach to the nutritional elements required. From an 
analysis of many human milks we know what should constitute a 
child's food. Cow's milk, however, differs from human milk in im- 
portant features. 

COWS MILK 

As cow's milk furnishes the most available basis of nutrition for 
the infant who is deprived of the mother's milk, it is essential in order 
to secure the best results from its use as an infant food, that it contain 
total solids between 12 and 13 per cent, and that the solids be repre- 
sented in the nutritional elements in somewhat the following pro- 
portions : 

Fat 3.5 to 4 per cent. 

Sugar 4 to 4.5 " 

Total proteid 3.5 to 4 " 

Ash 0.7 to 0.9 

Specific gravity 1.028 to 1.033 

In order that the milk may be of a fairly constant strength, herd- 
milk is to be preferred to the product of one or two cows, as the quality 
of the latter may vary considerably from day to day. It has been 
demonstrated that the best cows for this purpose are what are known 
as ''grade cows," that is, not pure bred. Such cows thrive better, are 
more easily kept healthy, and are more uniform in the nutritional 
equivalent of their milk-supply than are high-class registered herds of 
the Alderney or Jersey strain. 

There are several proteids of cow's milk, of which the most impor- 
tant and best known are casein, which forms the curd, and lactalbumin, 
the proportion being about three parts casein to one part of lactal- 
bumin. In mixed milk from several cows this proportion is by no 
means constant. The sugar of cow^s milk is lactose, which is less 
sweet to the taste than cane-sugar or granulated sugar or maltose 
derived from starch. That cow's milk shall contain a certain quantity 
4 



50 THE PRACTICE OF PEDIATRICS 

of total solids, and that it shall be of a specific gravity within certain 
limits, is necessary in order that it may supply nourishment to the 
child. Another most important feature to be taken into consideration 
is cleanliness, which naturally brings us to a consideration of the 
bacteriology of milk — a large subject which can be but briefly referred 
to here. Milk fresh from the udder contains very few bacteria, parti- 
cularly if the first two or three jets from each teat are discarded. The 
time for bacterial contamination is during the milking and while the 
milk remains in the stable. Certain forms of bacteria are harmless, 
and it is impossible to have a milk absolutely free from bacteria. 
What we need to know is how dangerous bacteria get into the milk, 
and how they cause changes that may convert it into a poison of 
greater or less virulence. 

Harmless Bacteria.— The souring of milk is the result of the pres- 
ence of bacteria which produce changes in the sugar-of-milk, with the 
formation of lactic acid. The "turning" of milk during a thunder- 
shower is due to certain changes in the atmosphere that aid in the 
development of the bacteria which convert lactose into lactic acid. 

Harmful Bacteria.- — Bacteria of decomposition, under conditions 
favorable to their growth, attack the proteid constituents of the milk, 
producing putrefactive changes with evolution of poisons which may be 
of the greatest virulence. The putrefactive bacteria are always pres- 
ent in stables where manure is allowed to collect and where cleanliness 
is not observed. When we remember what a culture-field milk affords 
to bacteria, and when we see the manure and the surroundings in 
which milk is often drawn, it is not surprising that the milk should 
contain many millions of bacteria to a cubic centimeter. They may 
enter the milk from the dust in the stable, — a very fruitful source, — 
or they may find entrance from the milker's hands or from droppings 
of fine particles of manure from the belly of the cow. Bacteria from 
these sources are among the most dangerous forms found in milk. 
When bacteria once gain entrance into the milk, their growth is most 
rapid. 

Market Milk. — The legal standards for pure milk in most instances 
relate only to the chemical composition of the milk. The laws of 
most of the States call for 12 per cent, of total solids, and at least 3 per 
cent, of fat. If the milk contains less than these percentages, it is 
considered impure, even if it is just as it was when it left the cow's 
udder. Some cows give milk considerably below this standard. The 
chemical analysis of milk does not show whether it is suitable for use 
as an infant food, this point being decided according to its freshness 
and the care with which it has been handled with reference to the 
exclusion of bacteria and the prevention of their growth. The produc- 
tion of clean, safe milk is expensive. It costs at least two cents a quart 
to produce milk, without allowing anything for the labor of caring for 
the cows. The milk must be carried to the consumer, which is also 
expensive. 

Certified Milk. — The best grade of milk, and the one which should 



51 

be used in feeding infants whenever possible is known as "certified 
milk," and is produced under the direction of what is known as a '' milk 
commission." The establishing of "milk commissions" in different 
cities throughout the country has been the means of securing a much 
better milk-supply than was formerly possible, and has unquestionably 
been instrumental in saving thousands of lives. To Dr. H. L. Coit, of 
Newark, N. J., is due the credit of organizing the first milk commission. 
Certified milk must conform to certain standards as to its nutritional 
value and as to the number of bacteria per cubic centimeter. These 
standards are established by a committee of medical men who com- 
pose the milk commission, and who have complete control of the dairy 
and its entire output. 

The Milk Commission of the New York County Medical Society 
requires a standard of milk not containing over 10,000 bacteria in a 
cubic centimeter. When a dairyman has shown to the satisfaction of 
the Commission that he can produce a milk up to the required stand- 
ard, he is allowed to attach to his bottles milk labels furnished by the 
Commission certifying to that fact. Milk thus "certified" is taken 
from the delivery wagon from time to time and subjected to examina- 
tion by their bacteriologist in order to determine whether it conforms 
to the requirements of the Commission. In order to show the care 
and supervision necessary for the production of certified milk, the 
requirements of the Milk Commission of the New York County 
Medical Society for the Production of "certified milk" are given in 
full.* 

"The most practicable standard for the estimation of cleanliness in 
the handling and care of milk is its relative freedom from bacteria. 
The Commission has tentativel}^ fixed upon a maximum of 10,000 
germs of all kinds per cubic centimeter of milk, which must not be 
exceeded in order to obtain the indorsement of the Commission. This 
standard must be attained solely by measures directed toward scrupu- 
lous cleanliness, proper cooling, and prompt delivery. The milk 
certified by the Commission must contain not less than 4 per cent, of 
butter-fat on the average, and must possess all the other characteristics 
of pure, wholesome milk. 

"In order that dealers who incur the expense and take the pre- 
cautions necessary to furnish a truly clean and wholesome milk may 
have some suitable means of bringing these facts before the public, the 
Commission offers them the right to use caps on their milk-jars stamped 
with the words: 'Certified by the New York County Medical Society 
Milk Commission.' 

"Rules for the Producer. — 1. The Barnyard. — The barnyard 
should be free from manure and well drained, so that it may not har- 
bor stagnant water. The manure which collects each day should not 
be piled close to the barn, but should be taken several hundred feet 
away. If these rules are observed not only will the barnyard be free 
from objectionable smell, which is always an injury to the milk, but 
* Chapin: "Infant Feeding." 



52 THE PRACTICE OF PEDIATRICS 

the number of flies in summer will be considerably diminished. These 
flies, in themselves, are an element of danger, for they are fond of both 
filth and milk, and are liable to get into the milk after having soiled 
their bodies and legs in recently visited filth, thus carrying it into the 
milk. Flies also irritate cows, and by making them nervous reduce the 
amount of their milk. 

''2. The Stable. — In the stable the principles of cleanliness must 
be strictly observed. The room in which the cows are milked should 
have no storage loft above it ; where this is not feasible, the floor of the 
loft should be tight, to prevent the sifting of dust into the stable 
beneath. The stable should be well ventilated, lighted, and drained, 
and should have tight floors, preferably of cement. They should be 
whitewashed inside at least twice a year, and the air should always be 
fresh and without bad odor. A sufficient number of lanterns should 
be provided to enable the necessary work to be done properly during 
dark hours. There should be an adequate water-supply and the 
necessary wash-basins, soap, and towels. The manure should be 
removed from the stalls twice daily, except when the cows are outside 
in the fields the entire time between the morning and afternoon milk- 
ings. The manure gutter must be kept in a sanitary condition, and 
all sweeping and cleaning must be finished at least twenty-minutes 
before milking, so that at that time the air may be free from dust. 

*'3. Water-supply. — The whole premises used for dairy purposes, 
as well as the barn, must have a supply of water, absolutely free from 
any danger of pollution with animal matter, sufficiently abundant for 
all purposes, and easy of access. 

''4. The Cows. — The cows should be examined at least twice a year 
by a skilled veterinarian. Any animal suspected of being in bad health 
must be promptly removed from the herd, and her milk rejected. 
Never add an animal to the herd until it has been tested for tuberculosis 
and it is certain that it is free from disease. Do not allow the cows to 
be excited by hard driving, abuse, loud talking, or any unnecessary dis- 
turbance. Do not allow any strongly flavored food, like garlic, which 
will affect the flavor of the milk, to be eaten by the cows. 

"Groom the entire body of the cow daily. Before each milking 
wipe the udder with a clean damp cloth, and, when necessary, wash it 
with soap and clean water and wipe it dry with a clean towel. Never 
leave the udder wet, and be sure that the water and towel used are 
clean. If the hair in the region of the udder is long and not easily kept 
clean, it should be clipped. The cows must not be allowed to lie down 
after being cleaned for milking, until the milking is finished. A chain 
or rope must be stretched under the neck to prevent this. 

''All milk from cows sixty days before and ten days after calving 
must be rejected. 

''5. The Milkers, — The milker should be personally clean. He 
should neither have nor come into contact with any contagious disease 
while employed in milking or handling milk. In case of any such 
illness in the person or family of any employee in the dairy, such em- 



53 

ployee must absent himself from the dairy until a physician certifies 
that it is safe for him to return. 

*' Before milking, the hands should be thoroughly washed in warm 
water with soap and a nail-brush and well dried with a clean towel. 
On no account should the hands be wet during the milking. 

''The milking should be done regularly at the same hour morning 
and evening, and in a quiet, thorough manner. Light-colored, wash- 
able outer garments should be worn during milking. They should be 
clean and dry, and when not in use for this purpose, should be kept in a 
clean place protected from dust. Milking-stools must be kept clean. 
Iron stools painted white are recommended. 

''6. Helpers, Other than Milkers. — All persons engaged in the stable 
and dairy should be reliable and intelligent. Children under twelve 
years should not be allowed in the stable during milking, since in their 
ignorance they may do harm, and from their liability to contagious 
diseases they are more apt than older persons to transmit them 
through the milk. 

"7. Small Animals. — Cats and dogs must be excluded from the 
stable during the time of milking. 

'' 8. The Milk. — The first few streams from each teat should be dis- 
carded, in order to free the milk-ducts from milk that has remained in 
them for some time and in which bacteria are sure to have multiplied 
greatly. If, in any milking, a part of the milk is bloody or stringy or 
unnatural in appearance, the whole quantity of milk yielded by that 
animal must be rejected. If any accident occurs by which the milk 
in a pail becomes dirty, do not try to remove the dirt by straining, 
but reject all the milk and cleanse the pail. The milk-pails used should 
have an opening not exceeding eight inches in diameter. 

''Remove the milk of each cow from the stable, immediately after 
it is obtained, to a clean room, and strain it through a sterilized strainer. 

"The rapid cooling of milk is a matter of great importance. The 
milk should be cooled to 45°F. within one hour. Aeration of pure milk 
beyond that obtained in milking is unnecessary. 

"All dairy utensils, including bottles, must be thoroughly cleansed 
and sterilized. This can be done by first thoroughly rinsing in warm 
water, then washing with a brush and soap or other alkaline cleansing 
material and hot water, and thoroughly rinsing. After this cleansing, 
they should be sterilized with boiling water or steam, and then kept 
inverted in a place free from dust. 

"9. The Dairy. — The room or rooms where the bottles, milk-pails, 
strainers, and other utensils are cleaned and sterilized should be sepa- 
rated somewhat from the house, or when this is impossible, have at 
least a separate entrance, and be used only for dairy purposes, so as to 
lessen the danger of transmitting through the milk contagious diseases 
which may occur in the home. 

"Bottles, after filling, must be closed with sterilized discs and 
capped so as to keep all dirt and dust from the inner surface of the 
neck and mouth of the bottle. 



54 THE PRACTICE OF PEDIATRICS 

/' 10. Examination of the Milk and Dairy Inspection. — In order that 
the dealers and the Commission may be kept informed of the character 
of the milk, specimens taken at random from the day's supply must be 
sent weekly to the Research Laboratory of the Health Department, 
where examinations will be made by experts for the Commission, the 
Health Department having given the use of its laboratories for this 
purpose. 

" The Commission reserves to itself the right to make inspections of 
certified farms at any time and to take specimens of milk for examina- 
tion. It also reserves the right to change its standards in any reason- 
able manner upon due notice being given the dealers." 

Naturally, milk produced in this way is more expensive than when 
little or no care is used, more help is required, and help of a more ex- 
pensive type. Certified milk, or its equivalent, is sold in New York 
City at prices ranging from 15 to 20 cents a quart. 

Examination of Cow's Milk. — In the use of cow's milk, as in that 
of human milk, a chemical analysis is necessary, in order to know 
accurately the nutritional elements. The specific gravity varies from 
1.029 to 1.035. Milk is acid in reaction to phenolphthalein, and may 
be neutral to litmus. The Babcock milk-test machine is what is 
generally employed in examining cow's milk in laboratories and insti- 
tutions. The test consists in mixing the milk with strong sulphuric 
acid, which dissolves the proteids and liberates the fat, the quantity of 
which is read off from the graduated neck of the bottle used in mix- 
ing the milk and acid. Only the fat is determined in this way. Know- 
ing the fat and the specific gravity, one may readily determine the 
solids other than fat by adding to one-fourth of the specific gravity, 
reading to the right of the decimal point, one-fourth of the percentage 
of fat. 

MODIFIED MILK 

At one time it was thought that, by changing the percentage com- 
position of cow's milk and altering the reaction, it could be made prac- 
tically identical with human milk, and the term "modified milk" was 
applied to cow's milk so manipulated. A great variety of manipula- 
tions of cow's milk has been introduced, which often differ greatly in 
the principles involved. Yet to products of all these different manipu- 
lations the term ''modified milk" is applied. It may mean any one 
of a dozen or more different products. Cow's milk diluted with 
water and given as a food to an infant is called "modified milk." 
When sugar, cereal gruel, lime-water, bicarbonate of sodium, or citrate 
of sodium is added, it is still "modified milk." When a prescription 
is sent to the laboratory calling for definite amounts of fat, sugar, and 
proteids, the product furnished is "modified milk." When a mother 
is told to use a definite amount of cream, milk, sugar, and water, 
*' modified milk" is also the outcome. 

As a matter of fact, successful infant-feeding consists in what I 
have termed "milk adaptation," that is, modifying the milk to suit 



MODIFIED MILK 55 

the case in hand. The routine prescriber is content to prescribe 
*' modified milk," that which was originally supposed to be an imitation 
of human milk. The best-informed prescriber uses *'an adapted 
modified milk" which he decides is indicated. 

The analysis of mixed dairy milk shows it to contain approximately : 

4.0 per cent. fat. 

4.0 per cent, sugar. 

3.5 per cent, total proteid. 

Human milk contains approximately: 

4.0 per cent. fat. 

7.0 per cent, sugar. 

1.5 per cent, total proteid. 

The Aim of Milk Modification. — The first aim in the modification 
is to make the chief nutritional elements in the food prepared from 
cow's milk correspond grossly to the nutritional elements in the 
human milk. The proteid must be reduced, the sugar increased, and 
the fat reduced even slightly below that usually found in mother's 
milk, as the child's digestive capacity for cow's-milk fat is less by from 
15 to 25 per cent, than it is for human milk. 

The Proteid. — The proteid element in an infant's food is its chief 
nutritional content. This has to be reduced to approximately the pro- 
portions that exist in human milk, and the change can be accom- 
plished onlj^ by dilution. The diluent msiy be plain water or it may 
be a cereal gruel. The average cow's milk contains, as just mentioned: 

4.0 per cent. fat. 

4.0 per cent, sugar. 

3.5 per cent, total proteid. 

If 8 ounces of milk is mixed with 8 ounces of water, we get a pint mix- 
ture with an approximate nutritional equivalent of: 

2.0 per cent. fat. 



Z/.u pel ueiiu. lau. 

2.0 per cent, sugar. 

1.75 per cent, total proteid. 



If 4 ounces of milk is mixed with 12 ounces of water, we have a 16- 
ounce mixture with an approximate nutritional equivalent of: 

1.0 per cent. fat. 

1.0 per cent, sugar. 

0.9 per cent, total proteid. 

If 6 ounces of milk is mixed with 10 ounces of water, a 16-ounce mix- 
ture is produced with an approximate nutritional equivalent of : 

1.5 per cent. fat. 

1.5 per cent, sugar. 

1.3 per cent, total proteid. 



56 THE PRACTICE OF PEDIATRICS 

By this simple dilution with water the desired proteid content of the 
food may be arrived at. 

The Sugar. — For nourishment for an infant, however, the mixture 
is weak in fat and very weak in sugar. The sugar content is increased 
by the addition of milk-sugar or cane-sugar. It will be remembered 
that in human milk there is a sugar content of 7 per cent. The com- 
bination of full cow's milk and water as above gives a sugar content of 
2 per cent, or less, so that sufficient sugar must be added to make the 
increase approximately 7 per cent. What is necessary, then, is to in- 
crease the sugar content 5 per cent. A 1 per cent, sugar and water 
mixture would contain approximately 5 grains of sugar to the ounce. 
A 6 per cent, sugar mixture would contain 30 grains to the ounce, and 
as our dealings are with a 16-ounce mixture, we require an addition 
of 16 times 30 grains of sugar-of-milk, or 480 grains, so that if we direct 
that a pint mixture contain 6 ounces of a 4-4-3.50 milk, 10 ounces 
water, 1 ounce milk-sugar, there would be an approximate nutritional 
equivalent of: 

1.5 per cent. fat. 

7.5 per cent, sugar. 

1.3 per cent, total proteid. 

Or if the mixture were 4 ounces milk, 12 ounces water, 1 ounce milk- 
sugar, there would be an approximate nutritional equivalent of: 



1.0 per cent. fat. 

7.0 per cent, sugar. 

0.9 per cent, total proteid. 



The Fat. — While a child of from two to four months might thrive 
on the above formulas, the fat is obviously deficient and must be 
increased. This is accomplished by the use of cream. Cream of the 
same age as the milk should be used. When this method of feeding is 
carried out, in order to secure a suitable cream, a quart bottle of milk 
from a mixed herd of grade cows is allowed to stand at a temperature 
of 40° or 50°F. for five hours, when a cream which will be referred to as 
^'gravity cream'' (p. 73) will be produced of the approximate strength 
of: 

16.0 per cent, butter-fat. 

3.2 per cent, sugar. 

3.2 per cent, total proteid. 

These were the percentages obtained in an analysis made for me from 
the Walker-Gordon Laboratory milk, which is produced by grade cows 
and has an average milk strength as regards the nutritional elements, 
and may therefore be taken as a guide in using gravity cream for infant- 
feeding. Cream from well-fed Jersey cows procured in this way will 
contain from 20 to 24 per cent, of fat. One ounce of gravity cream 
with 15 ounces of water gives a pint mixture with a nutritional equiva- 
lent of: 



MODIFIED MILK 



57 



1.0 per cent. fat. 

0.2 per cent, sugar. 

0.2 per cent, total proteid. 

Two ounces of gravity cream and 14 ounces of water give an approxi- 
mate nutritional equivalent of: 

2.0 per cent. fat. 

0.4 per cent, sugar. 

0.4 per cent, total proteid. 
We now wish by using gravity cream (see p. 73) 
to raise the fat in the milk and sugar-water mixtures 
given above. In using the cream, all must be removed 
and mixed, as the upper layers in the bottle are much 
richer in fat than those nearer the milk. For this 
skimming process the Chapin dipper (Fig. 4) is em- 
ployed. Milk which is rapidly cooled immediately 
after being drawn and kept at a temperature of 50°F. 
or lower may be skimmed at the end of five hours, 
when all the cream that will rise will have done so. 

ILLUSTRATIVE FOOD FORMULAS 



Approximate Percentage 
Equivalent 

Fat 2.0 

Sugar 7.2 

Total proteid 1.1 

Approximate Percentage 
Equivalent 

Fat 3.0 

Sugar 7.4 

Total proteid 1.3 



Gravity cream 1 ounce 

Milk 4 ounces 

Milk-sugar 1 ounce 

Water 11 ounces 

Gravity cream 2 ounces 

Wilk 4 ounces 

Milk-sugar 1 ounce 

Mater 10 ounces 

In the event of a weak proteid digestion in a young 
baby, gravity cream alone may be used temporarily; 
thus 3 ounces cream, 1 ounce milk-sugar, 12 ounces 
water, 1 ounce lime-water, which mixture gives an 
approximate nutritional equivalent of: 

3.0 per cent. fat. 

6.6 per cent, sugar. 

0.6 per cent, total proteid. 



Fig. 4 
filling and 
ing Chapin 



.— Self- 
em pty- 
dipper. 



Of if a weaker food is desired for a younger infant, we may use 2 ounces 
gravity cream, 1 ounce milk-sugar, 133^^ ounces water, 3^^ ounce lime- 
water, which mixture gives an approximate equivalent of: 

2.0 per cent. fat. 

6.4 per cent, sugar. 

0.4 per cent, total proteid. 

In the event of a good proteid digestion and poor fat digestion, full 
milk along with sugar and water should be used; thus 53^ ounces milk, 
10 ounces water, 1 ounce milk-sugar, 1% ounces lime-water, which 
mixture gives an approximate equivalent of: 



58 THE PRACTICE OF PEDIATRICS 

1.33 per cent. fat. 

7.33 per cent, sugar. 

1.17 per cent, total proteid. 

Average skimmed milk with the gravity cream removed contains about 
1 per cent, fat, 3.5 per cent, sugar, and 3 per cent, proteid. If for any 
reason a particularly weak fat food is required, skimmed milk may be 
used: 53^ ounces skimmed milk, 9 ounces water, 1 ounce milk-sugar, 1% 
ounces lime-water, which mixture gives an approximate equivalent of : 

0.33 per cent. fat. 

7.17 per cent, sugar. 

1.00 per cent, total proteid. 

If a stronger skimmed milk mixture is required, it may be prepared as 
follows: 8 ounces skimmed milk, 8 ounces water, 1 ounce milk-sugar, 
which mixture gives an approximate nutritional equivalent of: 

0.50 per cent. fat. 

7.75 per cent, sugar. 

1.50 per cent, total proteid. 

It will thus be seen that with milk, cream, and sugar-of-milk, food 
of every possible strength may be made. If lime-water is used, it 
simply takes the place of the milk diluent and replaces so much water. 
This method of milk preparation is more accurate than when top-milk 
mixtures are used, but it has the disadvantage of requiring two quarts 
of milk during the entire feeding period, one to supply the milk and the 
other the cream, all of which must be removed and mixed before any of 
it is used in the food. 

The following formulas for the different ages may be found useful 
for well babies: 

From the first to the third day: 

Milk-sugar ^^ ounce 

Boiled water 16 ounces 

3^^ to 1 ounce every two or three hours 

which mixture gives an approximate nutritional equivalent of 3 per 
cent, sugar. 

From the third to the tenth day: 

Gravity cream ^ ounce Approximate Percentage Equivalent 

Milk 43^^ ounces Fat 1 . 25 

Milk-sugar 1^ ounces Sugar 6 . 85 

Lime-water 1 ounce Total proteid . 75 

Boiled water to make 24 ounces 

Seven feedings in twenty-four hours; 2 to 3 ounces at each feeding. 
One ounce = 12.8 calories. 

From the tenth to the twenty- first day: 

Gravity cream 1% ounces Approximate Percentage Equivalent 

Milk 6K ounces Fat 1.7 

Milk-sugar 2 ounces Sugar 7.0 

Lime-water 2 ounces Total proteid . 89 

Water to make 30 ounces 

Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. 
One ounce = 14.4 calories. 



MODIFIED MILK 59 

From the third to the sixth week: 

Gravity cream 23^ ounces Approximate Percentage Equivalent 

Milk 8 ounces Fat 2.25 

Milk-sugar 2 ounces Sugar 7 . 25 

Lime-water 2 ounces Total proteid 1.13 

Water to make 32 ounces 

Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. 
One ounce = 16.6 calories. 

From the sixth week to the third month: 

Gravity cream 3 ounces Approximate Percentage Equivalent 

Milk 9 ounces Fat 2.6 

Milk-sugar 2 ounces Sugar 7.4 

Lime-water 23^ ounces Total proteid 1.3 

Water to make 32 ounces 

Seven feedings in twenty-four hours; 4 to 5 ounces at each feeding. 
One ounce = 18 calories. 

From the third to the fifth month: 

Gravity cream 4 ounces Approximate Percentage Equivalent 

Milk 15 ounces Fat 3.1 

Milk-sugar 2 ounces Sugar 6.8 

Lime-water 3 ounces Total proteid 1.6 

Water to make 40 ounces 

Six feedings in twenty-four hours; 5 to 6 ounces at each feeding. 

One ounce = 18.9 calories. 

From the fifth to the seventh month: 

Gravity cream 5 ounces Approximate Percentage Equivalent 

Milk 18 ounces Fat 3.6 

Milk-sugar 2 ounces Sugar 6.6 

Lime-water 3 ounces Total proteid 1.9 

Water to make 42 ounces 

Five to six feedings in twenty-four hours; 6 to 7 ounces at each feeding. 
One ounce = 20.5 calories. 

After the fifth month it is my custom to add from one to three tea- 
spoonfuls of a cereal jelly to each feeding. This may be added to the 
milk mixture when it is made in the morning. Thus, if one teaspopnful 
is to be given at each feeding, where a child is getting six feedings, six 
teaspoonfuls of the jelly may be added to the entire quantity. 

From the seventh to the ninth month: 

Gravity cream 6 ounces Approximate Percentage Equivalent 

Milk 23 ounces Fat 3.9 

Milk-sugar 2 ounces Sugar 6.5 

Lime-water 3 ounces Total proteid 2.1 

Water to make 48 ounces 

Five feedings in twenty-four hours; 7 to 8 ounces at each feeding. 
One ounce =21.4 calories. 

From the ninth to the twelfth month: 

Gravity cream 7 ounces Approximate Percentage Equivalent 

Milk 32 ounces Fat 4.28 

Lime-water 4 ounces Sugar 7 . 25 

Milk-sugar 2>2 ounces Total proteid ...2.4 

Water to make 56 ounces 

Five feedings in twenty-four hours; 8 to 9 ounces at each feeding. 
One ounce =23.8 calories. 

Top-milk Feeding. — In using top-milk for infant-feeding the milk 
is allowed to stand in a quart bottle at a temperature of 45° to 50°F. 



60 THE PRACTICE OF PEDIATRICS 

five hours. The quantity needed is then removed from the top of the 
bottle with a Chapin dipper (Fig. 4) and diluted as desired with water 
or gruel to which sugar-of-milk and lime-water are added. The milk 
selected should be the cleanest obtainable from grade cows; usually 
the most expensive is the best. 

From a quart bottle of milk on which the cream has risen, dip from 
the top with a Chapin dipper 16 ounces and mix. From average milk 
this should contain: 



7.0 per cent. fat. 

3.2 per cent, sugar. 

3.2 per cent, total proteid. 



The following top-milk formulas are suggested for the various ages 
noted : 

From the third to the tenth day: 

Milk (top 16 OZ.) 6 ounces Approximate Percentage Equivalent 

Lime-water % ounce Fat 1 . 75 

Milk-sugar 13^ ounces Sugar 6.6 

Boiled water to make 24 ounces Total proteid 0.8 

Seven feedings in twenty-four hours; 2 to 3 ounces at each feeding. 
One ounce = 12.5 calories. 

From the tenth to the twenty-first day: 

Milk (top 16 OZ.) 7^^ ounces Approximate Percentage Equivalent 

Lime-water 2 ounces Fat 1 . 75 

Milk-sugar 2 ounces Sugar 6.8 

Water to make 30 ounces Total proteid 0.8 

Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. 
One ounce = 14.2 calories. 

From the third to the sixth week: 

Milk (top 16 OZ.) 10 ounces Approximate Percentage Equivalent 

Lime-water 2 ounces Fat 2.2 

Milk-sugar 2 ounces Sugar 7.0 

Water to make 32 ounces Total proteid 1.0 

Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. 
One ounce = 16 calories. 

From the sixth week to the third month: 

Milk (top 16 OZ.) 12 ounces Approximate Percentage Equivalent 

Milk-sugar 2 ounces Fat 2.6 

Lime-water 2 ounces Sugar 7.2 

Water to make 32 ounces Total proteid 1.2 

Seven feedings in twenty-four hours; 4 to 5 ounces at each feeding. 
One ounce = 17.5 calories. 

From the third to the fifth month: 

After this age two bottles of milk are required, 16 ounces being 
taken from the top of each bottle and mixed. At this time a cereal 
jelly is usually added to the food. 

Milk (top 16 OZ.) 18 ounces Approximate Percentage Equivalent 

Milk-sugar 2 ounces Fat 3.15 

Lime-water 3 ounces Sugar 6.4 

Water to make 40 ounces Total proteid 1.4 

Six feedings in twenty-four hours; 5 to 6 ounces at each feeding. 
One ounce = 18.3 calories. 



MODIFIED MILK 61 

From the fifth to the seventh month: 

Milk1(top 16 OZ.) 21 ounces Approximate Percentage Equivalent 

Milk-sugar 2 ounces Fat ' 3 . 50 

Lime-water 3 ounces Sugar 6.4 

Water to make 42 ounces Total proteid 1.6 

Five to six feedings in twenty-four hours; 6 to 7 ounces at each feeding. 
One ounce = 19.6 calories. 

From the seventh to the ninth month: 

Milk (top 16 OZ.) 27 ounces Approximate Percentage Equivalent 

Milk-sugar 214 ounces Fat 3.9 

Lime-water 3 ounces Sugar 7.0 

Water to make 48 ounces Total proteid 1.8 

Five feedings in twenty-four hours; 7 to 8 ounces at each feeding. 
One ounce = 21.7 calories. 

From the ninth to the twelfth month: 

Milk (top 16 OZ.) 35 ounces 

Milk-sugar 2>^ ounces Fat 4.3 

Lime-water 4 ounces Sugar 6.5 

Water to make 56 ounces Total proteid 2.0 

Five feedings in twenty-four hours; 8 to 9 ounces at each feeding. 
One ounce = 22.4 calories. 

After the twelfth month, plain cow's milk maj^ be given with the cereal 
jelly in addition to the other articles of diet suggested for a child one 
year old. (See p. 105.) 

Considerable latitude is allowed as to the amount of food which 
may be given at each feeding, because of the difference in the capacity 
of individual children. It will be observed that the total quantity of 
food prepared may be a few ounces more than the amount which the 
child will ordinarily take in twenty-four hours. This extra amount 
often serves a most useful purpose when a bottle is broken or the food 
is otherwise lost. The average well child will require daily about 30 
ounces of a suitably adapted food at the third month, about 36 ounces 
at the sixth month, and 40 to 45 ounces at the ninth to the twelfth 
month. 

Night Feedings. — After the third month the midnight feeding 
should be discontinued. Six feedings are sufficient, the first at 6 a. m. 
and the last at 10 p. m. 

Between 10 p. M. and 6 a. m. the child should sleep. Babies are 
easily weaned from the night bottle by substituting a bottle of boiled 
water or a milk mixture greatly diluted with water. The child soon 
discovers that this is not worth waking for. As a result of a full night's 
rest the digestive organs are better able to do their work, the appetite 
is increased, and a larger amount of food may be given at each feeding. 

The Quality of Milk Variable. — It is not claimed that the nutri- 
tional value as indicated by the percentage equivalents in either of 
the above series is absolutely correct. Milks necessarily differ in com- 
position. Only mixed dairy milk is referred to, the product of several 
grade cows. The feeding of the cows and their care also influence the 
quality of the milk. The percentages given indicate approximately 
the nutritional value and are sufficiently accurate for purposes of 



62 THE PRACTICE OF PEDIATRICS 

supplying satisfactory nutrition to well babies of the various ages, as 
I have abundantly proved to my own satisfaction. The fat will not 
be found too low for proper nutrition in any of the formulas given. It 
may be too high for proper digestion and require adjustment. The 
proteids as given are sufficient for nutrition if they are assimilated. 
They also may require reduction to meet special conditions which are 
referred to under Milk Adaptation (p. 62). The adjustment of the 
food to the individual constitutes what I have termed ''milk adapta- 
tion/' and suggestions for making the food fit the child's digestive 
capacity will be found under that caption. 

Adapted Milk. — In adapting milk for infant-feeding the milk must 
not only be '' modified" (p. 54), by which process the nutritional ele- 
ments are changed in their proportions so as to make them conform 
as nearly as possible to mother's milk, but more is required — the food 
must be adapted to the child's digestive capacity. 

If the modification of milk, as we formerly understood, constituted 
all that was required in infant-feeding, the artificial feeding of infants 
would be a comparatively simple matter: Some infants will take read- 
ily any reasonable modification which by experience has been found 
suitable for children of their age. The majority, however, who are fed 
on cow's milk, must be fed according to their digestive capabilities. 
Every feeding case must be studied from the individual standpoint. 
How best to nourish the individual can be learned only by a study of 
the patient himself. No process of manipulation by the addition of 
chemicals or gruels can convert cow's milk into human milk. Various 
means, however, are available sufficient to overcome the existing dif- 
ferences, thereby making a suitable food even for those who at first 
show signs of marked intolerance of cow's milk. The strength of the 
food and the feeding intervals required for average well children of the 
different ages are given in the chapters on Modified Milk, p. 54. 

Symptomatic Adaptation. — If the child is getting a food of suitable 
strength at proper intervals and becomes ill, the food as a whole may 
be beyond his digestive capacity, or there may be an incapacity for 
one or more nutritional elements. If the food as a whole is too strong, 
there is very commonly vomiting, which may become habitual, or there 
may be colic or constipation or diarrhea. If the food as a whole is too 
weak, the fact will be evidenced by hunger, failure to gain in weight, 
and usually by constipation. If sugar is given in excess — a compara- 
tively rare cause of trouble, if not more than 7 per cent, of milk-sugar 
is given — it will be indicated by the regurgitation of sour, watery 
material. A sour odor to the patient's breath and clothing indicates 
sugar excess. There may not be pronounced vomiting in such a case, 
but the repeated regurgitation when the patient is awake is sufficient 
to deprive him of a goodly amount of his daily food. The digestion of 
both fat and proteid may be markedly interfered with, and the whole 
digestion deranged as a result of what was primarily a sugar incapacity 
or sugar excess. When sugar is at fault, the indigestion may readily 
be corrected by washing out the stomach for a few days (p. 788) and 



MODIFIED MILK 63 

by reducing the sugar content of the food one-half. Later, after the 
condition is reheved, the sugar may gradually be. increased to the nor- 
mal percentage of 7. A child may be getting but a 2 per cent, cow's- 
milk-fat mixture and yet suffer from fat-indigestion. Excessive fat or 
fat incapacity also gives rise to vomiting and regurgitation in which 
particles of fat may often be seen. Fat, moreover, may cause frequent 
green, undigested stools, the passage of which is associated with marked 
tenesmus. Fat-diarrhea is often the outcome of fat-indigestion. 
Cow's-rdilk fat was not intended for babies, and when it disagrees — 
since we cannot change its character — our only method of adaptation 
is to reduce the amount given, as with the sugar. 

Casein. — The casein in cow's milk is its important nutritional 
constituent, and in adapting cow's milk to a child's digestive capacity 
the casein is oftentimes a most difficult factor to deal with. Tempo- 
rarily it may be reduced with safety to a percentage below that of cow's 
milk — to 0.25 per cent., for instance — but it must be remembered that 
the patient cannot thrive or even long exist without this proteid ele- 
ment in the diet, so that a reduction will always be followed by malnu- 
trition. It is necessary, then, to give proteid, and successful infant- 
feeding means that we must adapt the proteid to the child's digestive 
capacity. This, fortunately, is oftentimes possible. 

The Use of Alkalis and Antacids. — The casein of human milk when 
it enters the infant's stomach separates into small, flocculent masses. 
Cow's milk entering the infant's stomach, without an addition of an 
alkali or other modifying medium, is precipitated by the pepsin in the 
stomach and forms a heavy curd, consisting of paracasein, which fails of 
digestion or assimilation, and at which the child's stomach oftentimes 
rebels. The adaptation of the casein of cow's milk to the child's diges- 
tive capacity, so as to maintain suitable nutrition, is a central point around 
which the whole subject of infant-feeding revolves. It will be noted in the 
formulas for cow's-milk feeding for different ages that lime-water is 
used as a diluent. This is used not simply as a diluent of cow's milk 
nor to render the milk alkaline, as has frequently been stated; it is 
used to prevent the coagulation of the casein and the resulting forma- 
tion of tough curds of paracasein. Simple dilution with water may 
make a smaller curd, but does not produce the flocculent character 
peculiar to human milk that follows the addition of alkalis and antacids 
to cow's milk. In the presence of an alkali the casein does not com- 
bine with the acid in the stomach; consequently the resulting acid 
coagulation does not take place. For this reason alkalis and antacids 
are added to cow's milk. 

Poynton, of London, advocates the use of citrate of soda with a view 
to preventing the solid coagulation of the casein. It is claimed that by 
using citrate of soda, 1 grain to the ounce, sodium paracasein is pro- 
duced, which is a fluid. Citric acid is liberated and unites with the 
calcium, forming the citrate of calcium, which is absorbed. 

Signs of indigestion of the casein in the milk are usually pain and 
discomfort. There are usually acute attacks of colic. There may be 



64 THE PRACTICE OF PEDIATRICS 

constipation, or diarrhea alternating with constipation, associated with 
the passage of many hard curds in the stools, the patient losing steadily 
in weight. In such instances the best means of adaptation consists in 
reducing the amount of proteid to a total of 1 per cent, by dilution with 
water, and the addition of sufficient antacids, such as lime-water, 
bicarbonate of soda, or citrate of soda, to form a curd more readily 
attacked by the digestive juices. The writer feeds many hundreds of 
infants yearly, and is not in accord with the belief, which is now fashion- 
able, that the casein of cow 's milk is a factor of no importance in the adap- 
tation of cow 's milk. 

Whey-feeding. — Whey mixtures may be of temporary use in these 
cases. In whey the casein is largely removed — about 0.3 per cent, 
remaining. Analyses of whey show a nutritional equivalent of about: 

0.5 per cent. fat. 
0.9 per cent, lactalbumin. 
0.3 per cent, casein. 
4.5 per cent, sugar. 

As whey is ordinarily made, it is impossible to obtain a lower percentage 
of casein than 0.25. The amount of casein will oftentimes reach 0.5 
per cent, unless it is heated and strained a second time. The deficiency 
in fat may be overcome by adding gravity cream (p. 73) of the same 
age as the milk from which the whey is obtained, in the proportion of 
one or two ounces to a pint of whey. This, of course, carries with it a 
very small amount of casein, which may make a total beyond the 
child's digestive capacity. Low proteid must be given only during 
acute illness or indigestion, and should be a diet for temporary purposes 
until the child is able to care for more suitable nourishment. 

Adaptation by the Use of Cereal Gruels. — Cereals may be added to 
milk with advantage from two standpoints : they increase the nutritive 
value of the food mixture and when cooked with milk add very mate- 
rially to the digestibility of the milk, particularly if an antacid like 
carbonate of soda or citrate of soda is added in small amounts — 5 
grains to the day's allowance. That the cooking of milk with starch 
is of distinct value has been abundantly proven in the use of malt 
soup. . 

Malt-soup Feeding. — The use of Loefflund's malt-soup extract 
(a preparation of malt and potassium carbonate), Keller's formula, 
offers a most satisfactory method of making cow's milk assimilable. 
It is not well borne in vomiting eases nor those in which there is a 
tendency to looseness of the bowels. When either of these conditions 
exists skimmed milk may be temporarily substituted. 

In following this method of feeding, the milk strength considered 
suitable for the condition and age of the child may be used. Lime- 
water is not employed because of the presence of carbonate of potash 
in the malt. The malt and the flour, a considerable portion of the 
latter having been dextrinized, take the place of milk sugar or cane- 
sugar in the food mixture. 



MODIFIED MILK 65 

The chief use of this food is in malnutrition cases, in slow-growing 
infants, who though not actually ill, fail to show a satisfactory growth 
on any other food given. Time and again I have seen these children 
show surprising increase in weight without change in the milk strength 
when the malt-soup with its ^our accompaniment was used. In 
treating bottle-fed infants who suffer from colic and marked con- 
stipation this food has a considerable field of usefulness. 

Malt-soup extract is not to be used in the strength indicated on 
the bottle, as the amount is entirely too high. I have found the 
following method the most satisfactory: For a 30-ounce mixture, 
dissolve 1 ounce of the malt extract in the amount of water used. Mix 
and blend from 1 to 2 ounces (by measure) of Robinson's Barley Flour 
or Imperial Granum with the milk, cream, or top-milk required. If 
there is abdominal distention and flatulence or other evidence of 
carbohydrate incapacity, the amount of flour should be reduced per- 
haps one-half. The milk and flour mixture is to be strained and added 
to the solution of malt and water. It should then be placed over a 
slow fire and "simmered" for thirty minutes, with constant stirring. 

Instead of using wheat flour as directed on the package of malt 
soup, I have for some time been using Robinson's Barley Flour (baked 
barley flour) or Imperial Granum (baked wheat flour) with better 
results in many difficult cases than when raw wheat flour was used. 

In the event of constipation continuing, the amount of malt used 
may be doubled. Excess of malt, however, may produce vomiting, 
so that any increase should be made with caution. 

Eiweiss Milch (Protein Milk). — The Eiweiss Milch of Finkelstein 
and Meyer is prepared as follows: 

To one quart of milk heated to 100°F. add one junket tablet dis- 
solved in water, and stir for a few seconds. Stand at room tempera- 
ture until firmly coagulated: strain through gauze and wash curd 
twice with cold boiled water. Rub dry curd through fine wire sieve, 
gradually adding one pint of lactic-acid milk. Enough boiled water 
is then added to make one quart. 

Lactic Acid Milk. — ^Lactic acid milk is prepared as follows: 

One Lactone Tablet (Parke, Davis & Co.) is added to one quart 
skimmed milk, and allowed to stand at 98°F. for twenty-four hours. 

Eiweiss Milch (Protein Milk) is a most satisfactory diet for infants 
acutely ill with diarrheal disturbances. (One grain of saccharine may 
be added to each pint to make it more palatable.) It may be given 
with advantage when plain cow's milk is dangerous. It may be used 
at all ages. It is well taken by most infants after a few trials. It is 
usually well retained. The stools improve rapidly under its use, be- 
coming yellow and smooth. It constitutes a means of nutrition, which 
may be brought into use much earlier than plain modified cow's milk, 
thus taking the place of the cereal decoctions. 

Our plan in a given case of acute intestinal intoxication is as follows : 
Two teaspoonfuls of castor oil are given. This is followed by plain 
barley-water, one ounce to the pint, for twenty-four hours. At the 
5 



bb THE PRACTICE OF PEDIATRICS 

end of this time, regardless of the character of the stools^ the Eiweiss 
Milch is introduced. Aside from what action the protein milk may 
possess as a remedial agent, it furnishes a food that may be given with 
safety in all cases during a very trying period. I usually begin with 
equal parts of Eiweiss Milch and bariey-water and later increase the 
milk strength about 25 per cent. 

Children kept on the Eiweiss Milch for a considerable period rarely 
continue to do well, so that cow's milk is to be resumed as soon as it is 
thought safe, perhaps after a week or two. 

The Calorimetric Standard. — The calorimetric standard is based 
upon the amount of energy indicated in calories for each pound of body 
weight. A calorie is the amount of heat required to raise the tempera- 
ture of one liter of water 1°C. 

Heubner, of Berlin, several years ago began the employment of cal- 
orimetric principles in infant-feeding. His original observations, 
which were made on healthy breast-fed infants, weighed before and after 
each feeding, showed that under six months 100 calories were required 
daily for every kilogram of body weight. After the sixth month, the 
number of calories required gradually lessened, so that at the comple- 
tion of one year about 85 calories to each kilogram of body weight 
appeared to be necessary. 

Lamb has reduced Heubner 's figures to pounds. He gives the 
calorimetric requirements during the first three months of life as 45 
calories daily per pound of body weight, during the next three months 
from 40 to 45 calories daily per pound, decreasing gradually during the 
next six months, so that at the twelfth month from 32 to 35 calories 
daily per pound of body weight are necessary. 

The following table represents the caloric values of foods ordi- 
narily employed in infant feeding. 

CALORIC VALUES 

1 ounce 7 per cent, milk 27 . 5 

1 ounce 4 per cent, milk 20 

1 ounce Fat Free Milk 10 

1 ounce Breast Milk 20 

1 ounce Barley Flour 100 

1 ounce Barley Water (1 tablespoon to 1 pint). 2.0 

1 ounce Oat Flour 110 

1 ounce Imperial Granum 100 

1 ounce Milk Sugar 116 

1 ounce Dextro-Maltose 100 

1 ounce Malt Soup 80 

1 ounce Sweetened Condensed Milk 132 

1 ounce Unsweetened Condensed Milk 42 

CEREAL GRUELS; STARCH-FEEDING 

Much discussion has taken place concerning the use of cereals in 
infant-feeding. 

The cereals consist of plant embryos surrounded by a mass of highly 
nutritious proteids and carbohydrates in the form of starch, which 
nourish the embryonic plant until it becomes rooted in the ground. 



CEREAL gruels; STARCH-FEEDING 67 

As the developing plant needs nourishment it converts the starch into 
dextrin and maltose. Cereals are analogous to eggs in that the germ 
is packed away in a supply of exceedingly nutritious food, which in the 
process of development it converts into tissue. Almost all of the pre- 
pared infant foods are made from cereal flours, with or without the 
addition of a little dried milk or sugar; or from cereals in which the 
starch has been transformed into dextrin and maltose. The proprie- 
tary meal foods, which consist of baked flours of different kinds, are 
useful aids in infant-feeding and most useful as milk substitutes when 
milk must temporarily be withheld. The conversion of starch into 
dextrin by the baking process is so slight that it may be ignored. 
Robinson's barley flour, Cereo Co.'s barley flour and the other gruel 
flours, and Imperial Granum (baked wheat flour) require boiling before 
use. They may be prepared according to the instructions given in 
the formulary (p. 71). 

It is my custom in bottle-feeding to begin with a cereal from the 
fifth to the seventh month, by using a cereal water as a diluent of the 
milk mixture. For this purpose barley or granum is usually employed. 
Very often in out-patient work I begin with a cereal diluent very early 
in life in order to make the food mixture more nutritious. This method of 
feeding is useful when accurate modifications are not possible and when 
the child for any reason cannot take a milk formula as strong as age 
and nutritional requirements demand. Such cases are frequently 
seen in the marasmic, the malnutrition, and the difficult feeding class. 
The addition of two or three tablespoonfuls of flour to the daily food 
will increase its nutritive value not a little. That boiled starch may be 
digested by the youngest and most marasmic infant has been proved 
under my own observation. 

The principal use of these flours, however, is in the treatment of 
gastro-enteric diseases, where cereal va^y with safetj^ replace the milk 
for considerable periods of time. By eliminating milk from the diet 
and giving carbohydrates, a putrefactive culture-field is removed and 
a less favorable soil is furnished for the development of the intestinal 
bacteria; further, there are no by-products formed to produce intestinal 
toxemia or kidney irritation. Two even tablespoonfuls of these flours 
to one pint of water give approximately a food strength of 0.07 per 
cent, fat, 0.3 per cent, proteid, 2 per cent, carbohydrate. In order 
to increase the nutritive value, cane-sugar may, be added in sufficient 
quantity to bring the carbohydrate percentage up to 5. The addition 
of the sugar also makes the cereal more palatable, and therefore more 
acceptable to the patient. 

During an invasion of scarlet fever, pneumonia, or any of the ill- 
nesses of childhood which may be accompanied by great prostration, 
the usual foods, whatever their nature, should be withheld, and the 
cereal gruel alone or mixed with chicken or mutton broth used as a very 
satisfactory substitute. Likewise later in the disease it is never well 
to give full milk while fever and prostration are present. Cereal gruels 
are especially serviceable as diluents of the milk in conditions where 



68 THE PRACTICE OF PEDIATRICS 

this combination must often furnish the nutrition for days. The use 
of the baked-flour gruels, with sugar or without, as a means of nutri- 
tion should be continued only during the active symptoms of the disease, 
whether it is scarlet fever Or one of the intestinal diseases. In no sense 
are these gruels advocated as exclusive foods for infants or for growing 
children. I have seen many cases in which this error has been made 
with most disastrous results. 

The Infantas Capacity for Starch Digestion Proved hy Experiment. — 
It has been claimed with more or less tenacity by different writers that 
the young infant possesses no capacity for starch digestion. That 
the youngest infants may digest starch is now definitely established. 
The experiments of Moro, Zwiefel, Corwin, Hess* and the Authorf 
have proven the earlier beliefs erroneous. 

PEPTONIZED MILK 

Milk is peptonized, or predigested, for the purpose of partially or 
completely digesting the proteid before it is given to the patient. As 
a means of assistance in making a milk food assimilable the usefulness 
of peptonization is limited. So-called complete peptonization pro- 
duces a product with a decidedly bitter taste, which few children will 
take. Peptonized milk, however, has other uses than as a means of 
daily feeding. Peptonized milk in which there is a complete conversion 
of the casein has been most useful in two types of cases : 

For Gavage. — -During acute or chronic illness when a child cannot 
take food by the natural method, as in diphtheric paralysis, or when 
he will not swallow on account of an acute inflammatory disease of the 
throat, such as peritonsillitis, retropharyngeal abscess, or retropharyn- 
geal adenitis, or when he is in a comatose condition from any cause 
except intestinal infection, the feeding of completely peptonized milk 
by gavage (p. 790) is of inestimable value. 

For Nutrient Enema. — In conditions when stomach-feeding is im- 
possible either by gavage or the natural method — conditions met with 
in persistent vomiting due to acute cerebral diseases, in recurrent vomit- 
ing, in acute gastric indigestion — and as an accessory means of feeding 
when sufficient nourishment cannot be taken by the stomach, the colon- 
feeding of completely peptonized, skimmed milk has a decided field of 
usefulness, and in this way I often employ it. Feeding children by 
means of the bowel, however, is usually possible for a few days only, be- 
cause of the local irritation produced by the nutriment and by the pas- 
sage of the tube. Skimmed milk, peptonized, with the addition of 
the white of egg makes the best nutrient enema that I have used. 
It should be given at a temperature between 90° and 95°F. at from six- 
to eight-hour intervals. The tube should be introduced at least 9 
inches. In cases of recurrent vomiting I have repeatedly seen both 
hunger and thirst relieved by feeding in this way. The following are 
the different methods for the peptonization of milk: 
* American Journal Diseases of Children. 
t Kerley, Mason and Cray. 



MILK FOR TRAVELING 69 

Peptonization. — Immediate Process. — Fifteen minutes before feed- 
ing add from 3-^ to J^ of the contents of a Fairchild peptonizing tube to 
the milk mixture which is in the nursing-bottle ready for use. Place 
the bottle in water at a temperature of from 110° to 120°F., and let it 
remain for fifteen minutes. The amount of the powder used and the 
degree of heat of the water depend, of course, upon the amount of 
milk in the nursing-bottle. 

Cold Process. — Put 4 ounces of cold water into a clean quart bottle 
and dissolve in it, by shaking thoroughly, the powder contained in one 
of the Fairchild peptonizing tubes; add a pint of cold fresh milk, shake 
the bottle again, and immediately place it upon ice — directly in con- 
tact with it. 

The bottle should always be well shaken before and after pouring 
out a portion of its contents. 

Partially Peptonized Milk. — Put 4 ounces of cold water and the 
powder contained in one of the Fairchild peptonizing tubes into a clean 
saucepan, and stir well; add a pint of cold fresh milk and heat to 
the boiling-point, stirring constantly. The heat should be so applied 
that the milk will come to a boil in ten minutes. Let it cool until luke- 
warm, then strain into a clean bottle or glass jar, cork tightly and keep 
in a cold place. The bottle or jar should always be well shaken before 
and after pouring out a portion. 

Partially peptonized milk, if properly prepared, will not become 
bitter. 

Completely Peptonized Milk. — Put 4 ounces of cold water and the 
powder contained in one of the Fairchild peptonizing tubes into a 
clean quart bottle and shake thoroughly; add a pint of cold fresh milk 
and shake again; then place the bottle in a pail or kettle of warm water 
at about 115°F., or not too hot to immerse the hand in it without dis- 
comfort. Keep the bottle in the water-bath for thirty minutes. Put 
it immediately upon ice — directly in contact with it. 

MILK FOR TRAVELING 

In making long journeys with infants by land or water, the feeding 
of the child is an important matter, and advice is often sought by moth- 
ers who wish to make the contemplated trip with the least possible 
risk. It is, of course, desirable that no change be made in the milk 
commonly used, and there are means of treating the milk and of keep- 
ing it which enable us to assure the patient of reasonable safety. It 
is my custom with city children to have the milk prepared at the 
Walker-Gordon Laboratory, where at a trifling expense small ice-boxes 
can be obtained which contain sufficient space for a few days' supply of 
milk and which can be conveniently carried on cars and boats. Larger 
boxes with a capacity of 12 quarts may be used for an ocean voyage. 
The smaller box will need refilling with ice, which is usually readily 
secured once or twice a day. The larger box for ocean voyages is 
packed in ice and placed in a cold-storage room of the vessel and will 
not need repacking during the trip. The milk prepared for a journey 



70 THE PRACTICE OF PEDIATRICS 

should be cooled to 45°F. as soon as it is drawn, and kept at this tem- 
perature until it can be sterilized at a temperature of 212°F. for twenty 
minutes. It should then be cooled rapidly to at least 50°F. and kept 
at this point until used. These directions can be carried out by any 
intelligent family. When this is done, the milk will be safe for use for 
the time required — from seven to eight days. Of course, laboratory 
milk is available for comparatively few. But the suggestion as to the 
making of an ice-box can be followed in any town or village, so that a 
milk laboratory is not essential. All that is required is the ice-box, ice, 
the quart fruit- jars or quart milk-bottles, and clean milk. Those who 
for any reason cannot avail themselves of the milk thus preserved 
will find in canned condensed milk a fairly good substitute. See 
Condensed Milk (p. 95). 

FOOD FORMULAS 

Beef -juice. — Take a round steak, cut into pieces the size of a horse- 
chestnut, place in a buttered pan in a hot oven, and bake for fifteen 
minutes ; remove from the pan and press out the blood ; add salt to the 
taste. 

Beef, Mutton, and Chicken Broth. — Take one pound of meat free 
from fat, cook for three hours in one quart of water, adding water from 
time to time, so that when the cooking is completed there will be one 
quart of broth. When the broth is cool, remove the fat, strain, and 
add salt to the taste. 

Scraped Beef. — Broil round steak slightly over a brisk fire. Split 
the steak and scrape out the pulp, using a, dull knife. 

Egg-water. — The white of one egg, thoroughly beaten in one pint 
of cold boiled water; strain; add salt to the taste. 

Oatmeal Jelly. — Oatmeal, four ounces; water, one pint; boil for 
three hours in a double boiler, water being added, so that when the 
cooking is completed a thin paste will be formed. This while hot is 
forced through a colander to remove the coarser particles. When cold, 
a semi-solid mass will be formed. 

Wheat Jelly and Barley Jelly. — Wheat jelly and barley jelly are 
made in the same way as oatmeal jelly, using cracked wheat or barley 
grains. 

Barley-water No. i. — Robinson's barley flour or Cereo Co.'s 
barley flour, one rounded tablespoonf ul ; water, one pint. Boil 
thirty minutes; strain; add water to make one pint. 

In making barley-water No. 2 two tablespoonfuls of the flour are 
used, and for No. 3 three tablespoonfuls are used. 

Imperial Granum is used in strengths identical with barley. 

Rice-water No. i. — Rice, one tablespoonf ul ; water, one pint; boil 
three hours, adding water from time to time, so that there is one pint of 
rice-water at the end of the three hours. 

In making rice-water No. 2 two tablespoonfuls of rice are used. 

Percentage Gruel Flours. — There has recently been put on the 
market in tin boxes, the covers of which are used as measures, a series 



THE PROPRIETARY FOODS 



71 



of flours, especially made for preparing cereal gruels and jellies of known 
percentage composition. On the labels are given only the cooking 
directions for preparing plain or dextrinized gruels, and their com- 
position when different quantities of flour are used. They are as 
follows : 



APPROXIMATE COMPOSITION OF GRUELS MADE FROM CEREO CO.'S 

GRUEL FLOURS 



Barley 






Legume' 



^j3 a 



Oat 



'3 g 

o t- 



fc, t- ^ 



Wheat 



o t- 



J a 



}i ounce flour to quart of 
water 

^2 ounce flour to quart of 
water 

% ounce flour to quart of 
water 

1 ounce flour to quart of 
water 

2 ounces flour to quart of 
water 

3 ounces flour to quart of 
water 

4 ounces flour to quart of 
water 



0.12 
0.24 
0.36 
0.48 
0.96 
1.44 
1.99 



0.60 
1.20 
1.80 
2.40 
4.80 
7.20 
9.60 



0.19 
0.39 
0.58 
0.78 
1.56 
2.34 
3.12 



0.53 
1.06 
1.59 
2.12 
4.24 
6.36 
8.40 



0.12 
0.24 
0.36 
0.48 
0.96 
1.44 
1.92 



0.60 
1.20 
1.80 
2.40 
4.80 
7.20 
9.60 



0.10 
0.20 
0.30 
0.40 
0.80 
1.20 
1.60 



0.62 
1.25 
1.88 
2.50 
5.00 
7.50 
10.00 



* Made from equal parts of peas, beans, and lentils. 

Dextrinized Barley-water. — Robinson's barley flour or Cereo Co.'s 
barley flour, three tablespoonfuls ; water, one pint; boil thirty min- 
utes; add water to make a pint. When lukewarm (100°F.), add one 
teaspoonful of Cereo; strain; this changes the starch into dextrinized 
maltose. 

Oatmeal-water No. i. — Oatmeal, one tablespoonful ; water, one 
pint; cook three hours and add water to make one pint. 

In making oatmeal-water No. 2 two tablespoonfuls of oatmeal are 
used. 

Whey. — Put one pint of fresh milk into a saucepan and heat it luke- 
warm — not over 100°F.; then add two teaspoonfuls of Fairchild's 
essence of pepsin and stir just enough to mix. Let it stand until flrmly 
jellied, then beat with a fork until it is finely divided; strain, and the 
whey, the liquid part, is ready for use. 

Junket. — To one quart of milk heated to 100°F. add one table- 
poon sugar, one junket tablet or half an ounce liquid rennet, and few 
drops of vanflla. Stand at room temperature until firmly coagulated, 
then place on ice. 

THE PROPRIETARY FOODS 

The foods on the market prepared for purposes of infant-feeding are 
very numerous. From our knowledge of the composition of mother's 



72 THE PRACTICE OF PEDIATRICS 

milk we learn what nutritional elements are required, and approxi- 
mately in what relative proportions these elements must exist, in order 
to supply the child with the food which nature intended him to have. 
The examination of the milk of thousands of nursing women shows that 
it contains from 2.5 to 4 per cent, fat, 6 to 7 per cent, sugar, and 1 to 
1.5 per cent, proteid; and this furnishes the balanced ration with nor- 
mal caloric requirements. These figures may be put down as the 
normal limits of human milk, and they are so, simply because the 
infant will thrive and grow when the nutritional elements in approxi- 
mately the above proportions are supplied to him. It is within these 
limits that the food must be kept in order that there may be normal 
growth and development ; though, of course, wide variations from these 
may be of temporary occurrence. While the child may exist and 
temporarily do fairly well on a percentage of fat lower than 2.5, he will 
invariably show defective growth if the proteid remains persistently 
under 1 per cent. The chief disadvantage in the infant foods which are 
used without the addition of cow's milk, lies in the fact that they do 
not contain the nutritional elements as they exist in normal breast-milk, 
and besides, of necessity, they are all cooked foods. 

In selecting a substitute for mother's milk (p. 48) one point is to be 
kept in mind, viz., the substitute should contain, in a readily assimilable 
form, the nutritional elements in approximately the proportions and 
forms in which they exist in mother's milk. All other feeding is de- 
fective. It is not well to put too much reliance on the analysis some- 
times published by the proprietary food manufacturer. This type of 
food is decidedly weak in animal fat for the reason that there is no 
means of keeping more than a small percentage of it in a food without 
its becoming rancid. When considerable percentages are indicated in 
the analysis, it is certain that the fat does not consist of butter-fat. 
The quantity of animal milk proteid is likewise deficient, and what is 
present has been cooked, which detracts materially from the value 
of the food in infant nutrition. Scurvy is not an infrequent result 
of the exclusive use of these foods. 

The Uses of Proprietary Dried-milk Foods. — It is to be remembered 
that this type of food is condemned because of its being an unsuitable 
food when used exclusively and persistently. Hysteric, general con- 
demnation of the proprietary infant foods is unjust. Throughout this 
book the uses of the proprietary foods will be mentioned from time to 
time and dwelt upon. Milk is often an important factor in the pro- 
duction of constipation; and the importance of this food in the nutrition 
of "runabout" and the older children who are on a general diet is sec- 
ondary. In such cases cow 's milk may be replaced by one of the pro- 
prietary dried-milk, malted foods which has a laxative effect. I some- 
times employ them in other disordered states. During acute illness 
and in convalescence from illness and in certain forms of malnutrition 
such foods are usually readily digested and may help us over difficult 
places. 



CREAM 73 

Proprietary Foods to Which Fresh Cow's Milk is Added. — These 
are not foods in the usual acceptation of the term, and if they are used 
alone, independent of milk, the patient will soon present a sorry spec- 
tacle. They are largely sugars, being composed of maltose and dex- 
trose, which are derived from starch. Some contain a considerable 
quantity of unconverted starch. When added to the water and milk 
mixtures they furnish the soluble carbohydrates and free starch, 
and thus fulfil this function of the food with results as good as, but 
usually no better than, those obtained with milk-sugar and a cereal 
gruel. Maltose is a laxative sugar. In some cases of constipation 
in the bottle-fed it may replace the milk-sugar in equal quantity, with 
decided advantage. In other cases this change to maltose is without 
effect. 

According to my observation, the statement that the addition of 
maltose to cow's milk facilitates its digestion is unfounded. I have 
tried this method in many cases, but have never been able in conse- 
quence to use a stronger cow's-milk mixture. The true test of such a 
measure is in treating the delicate and in feeding difficult cases, rather 
than well babies, who thrive regardless of the carbohydrate employed. 
The maltose preparations, then, in the sense that they may contain 
a small amount of proteid and a laxative sugar, are useful and to be 
recommended when such a carbohydrate is needed. 

The Proprietary Beef Foods. — Numerous preparations of this 
nature are on the market, and there has been abundant opportunity 
to test their value. Without going into a lengthy discussion as to how 
and under what conditions these preparations have been used, it is 
sufficient to say that as means of nutrition for children they play 
a very unimportant part. Their principal use is in illness, in which 
they act as a stimulant, and to a less degree as a food. They all make 
weak proteid mixtures when diluted so that the child can take them. 
The possibility of supplying any great amount of nutrition to the 
economy by their use is impossible; occasionally, however, they may 
be used to advantage. When milk is withdrawn, they may be added 
to the cereal gruel substitute. If there is diarrhea, great care must be 
exercised, as the proprietary beef preparations as well as beef-juice 
may aggravate this condition. On account of the creatinin which they 
contain, these foods should not be given in any of the forms of neph- 
ritis. Another feature which limits their use is that a child soon 
tires of them. They can rarely be given more than two or three times 
in twenty-four hours. Valentine's is the preparation I usually select. 
It may be given in solution — one-quarter to one-half teaspoonful to 
six ounces of the diluent. 

CREAM 

Market creams are known as "gravity cream" and "centrifugal 
cream." 

Gravity Cream. — Gravity cream is obtained by allowing the milk to 
stand for a certain length of time and then removing the cream. When 



74 THE PRACTICE OF PEDIATRICS 

milk, as soon as it is drawn, is placed in a quart milk-bottle or fruit-j ar 
and kept at a temperature of between 40° and 50°F., most of the 
fat will have risen at the end of five hours. When the cream is care- 
fully removed at the end of this time, from 0.3 to 0.8 per cent, of fat 
will remain in the milk. The fat content of gravity cream is subject to 
considerable variation, depending, of course, upon the richness of 
the milk and the manner in which it is treated, particularly as relates 
to rapid cooling. In the cream from well-kept grade cows the fat will 
average about 16 per cent. In cream from well-fed Alderney or Jersey 
herds it may be as high as 20 per cent., or higher. In cream from cows 
indifferently fed, in those which subsist entirely upon poor pasturage, 
the fat may be as low as 10 or 12 per cent. For, infant-feeding, gravity 
cream from the milk of grade cows is preferred. In using cream for 
infant-feeding all the cream to the milk line should be removed, as the 
upper layers are much richer in fat than that adjoining the milk. 
Further, when cream is mixed with milk both must be of the same age, 
as the addition of older, bacteria-laden cream to fresh milk will surely 
result in grave digestive disorders. 

Centrifugal Cream.. — Centrifugal cream is that which is removed by 
an apparatus known as a separator, which consists of a circular bowl for 
holding the milk, so arranged as to make from 3000 to 5000 revolutions 
a minute. This results in a rapid separation of the lighter fat from the 
milk. The fat collects near the center of the bowl and is removed by 
a device arranged for this purpose. The skimmed milk flows outward 
from another portion of the bowl by a similar device. Centrifugal 
cream is more difficult of digestion than gravity cream in that the 
natural emulsion in which the fat is held in the milk is destroyed by the 
process of centrifuging. Centrifugal cream may vary greatly in its 
fat content, depending upon the rapidity of operation of the separator. 
According to Babcock and Russell, the proteids also undergo a change, 
which does not add to their nutritive value. 

STERILIZATION AND PASTEURIZATION OF MILK 

The sterilization and pasteurization of milk, as the terms imply, are 
for purposes of preservation. The term sterilized milk is applied to 
milk that is heated to the boiling-point and maintained at that tem- 
perature, — 212°F., — for twenty minutes. The effect of sterilization 
is the destruction of the pathogenic bacteria, but it will not destroy 
the spores. Dr. R. G. Freeman's most recent observations show that 
heating the milk to 140°F. and maintaining it at this point for one 
hour is of advantage, in that the bactericidal effects are as good as 
when a higher temperature is used. At the same time the lower tem- 
perature produces less chemical change in the milk. Pasteurization 
consists in heating the milk to 167°F., maintaining it at that tempera- 
ture for thirty minutes, and then quickly cooling it. The effect of 
sterilization and the rapid cooling is to kill the existing bacteria, thus 
preventing, temporarily, further bacterial growth in the milk. 



STERILIZATION AND PASTEURIZATION OF MILK 



75 



The milk which is boiled in a bottle which is properly covered is 
** sterilized milk, " but if the steriliza- 
tion is to be carried on day after day 
an Arnold sterilizer (Fig. 5) should 
be used. For purposes of pasteuriz- 
ation the Freeman pasteurizer (Fig. 
6) is recommended. Pasteuriza- 
tion makes less change in the char- 
acter of the milk content; conse- 
quently there is less interference 
with its nutritive value. The tem- 
perature, too, 167°F., is sufficiently 
high to destroy pathogenic bacteria, 
including the Bacterium lactis and 
the Bacterium aerogenes, and hence 
acts as a valuable preservative, 
particularly during hot weather. 

Pasteurization Safest for Ex- 
clusive Use. — ^The question, 
whether milk should be given steri- 
lized, pasteurized, or raw has given 
rise to endless discussion in the press and in medical societies. 




Fig. 5. — Arnold sterilizer. 



Each 

















r^^i^P^»if[^'- ^^^^^^1 




tuKTn|un 


n 


i 


ttlp "^^1 


m 


1 
1 


1 


lU 



Fig. 6. — Freeman pasteurizer. 



method has its advocates. Among the pediatrists at the present time, 
some contend that milk should be sterilized, regardless of the season 



76 THE PRACTICE OF PEDIATRICS 

of the year, the character of the milk, or the station in life of the 
patient; others maintain that invariably it should be given raw, regard- 
less of the above-mentioned conditions; while still others are devoted 
to pasteurization. If any of the methods were to be used exclusively, 
pasteurization, being the safest, should be selected. Judging from my 
own experience in the matter of the heating of milk for infant foods, the 
subject should be considered from a broad standpoint. There is no one 
way of heating milk that is invariably the best. According to my 
observation, there are several factors which determine which is the 
proper procedure in a given case. 

Raw Milk Preferred if Fresh and Pure. — There is no doubt what- 
ever that the less the milk is heated, the better food it is for the average 
well baby, provided it is clean when procured and can be kept clean and 
sweet until it is used. (See Cow's Milk, p. 49.) This is possible in 
some of our dairies of the better class ; it is possible with many who live 
in the country, or who go to the country for the summer and who keep 
their own cows or who get their milk-supply from a neighboring source 
which they can control. Under such conditions the milk may be given 
raw during the entire year. 

When, however, the milk has to be shipped a considerable distance 
during the summer, when its safety depends upon the industry and 
carefulness of the employees of a milk-farm, I find it advisable to pas- 
teurize the milk during the heated term; therefore the majority of my 
private feeding cases get raw milk during eight months of the year and 
pasteurized milk four months. Sterilized milk is never used among 
these patients except during an ocean journey (see Milk for Traveling, 
p. 69) or a long-distance journey by land. Among out-patients, after 
feeding many thousands of them, I find the following scheme the safest : 
From May 1st until October 1st the milk is boiled (sterilized). These 
people, most of them, cannot afford a pasteurizer or sterilizer or under- 
stand the use of either. From October 1st to May 1st the milk is 
given raw. Pasteurization would be preferable, but it is possible with 
but very few dispensary patients. Even the giving of cooked milk, 
which unquestionably often becomes infected after cooking, is attended 
with no little risk to the child, as is shown by the death records of 
bottle babies during the summer. The giving of the cheap market 
milk raw to infants of the tenements during the heated term in any 
large city can only help to increase the teVrible mortality of this 
season. 

The object of heating the milk should always be explained to the 
mother so that she may appreciate the necessity of keeping it carefully 
covered and properly caring for it afterward. The idea is prevalent 
among uninformed people that after sterilization but little further 
protection is required. When I am satisfied the out-patients have 
not the requisite intelligence nor the means for keeping cow's milk 
during the summer, such as an ice-box and ice, I discontinue the 
ordinary milk-feeding for the hot months and use condensed milk in- 
stead (p. 95). 



THE EFFECT OF HEATING MILK UPON ITS ASSIMILATION 77 

THE EFFECT OF HEATING MILK UPON ITS ASSIMILATION 

Concerning the treatment of milk in order to make it easier of utili- 
zation we have much to learn. The milk proteids lend themselves to 
influences which entirely change their character, and affect their utili- 
zation by the infant. The heating of milk influences its digestibility 
and heating with different substances produces further changes in this 
respect. 

As previously stated, evaporated milk is easily and effectively 
utilized by the infant with a very weak digestive system, and this 
milk has been subjected to a heating process. 

A certain child cannot take fresh cow 's milk, modify and adapt it as 
we will. We give him evaporated milk of the same nutritional value 
and he thrives. This I have demonstrated in many private cases and 
at the Babies' and New York Nursery and Child's Hospitals. The 
digestive ferments were unchanged and the food capacity remained 
the same ; the change that took place was in the most important of the 
milk constituents, the proteid content. The degree of heat used and 
the length of its application also have a controlling influence on the 
digestibility of milk. The most favorable effects are produced through 
heating milk in the presence of starch and an alkali or antacid. 

For example, an infant suffering from malnutrition is given a for- 
mula of — 

10 ounces milk (top 15). 
1 ounce milk-sugar. 

J-^ ounce barley flour (Cereo). 

20 ounces water. 

10 grains bicarbonate of soda. 

The food agrees to the extent that the child is comfortable, but he fails 
to make a substantial gain. He gains and loses an ounce or two weekly. 
We now order that the milk and the barley be cooked together in a 
double boiler for thirty minutes and that water be added at the com- 
pletion to make up for that which passes off in evaporation. The food 
is given in the same amount at the same interval, and at once the child 
begins to take on weight. The feeding schemes have been identical 
excepting that in the latter we have added heat. Such an outcome 
will not take place in every case, but I have demonstrated this effect 
time and again. 

Repeatedly, when an infant has been brought to me because of mal- 
nutrition, although the child was getting a rational cow's milk formula, 
I have continued the milk strength as it was, simply changing the 
carbohydrate, milk-sugar, or dextromaltose to starch and malt soup, 
mixed together with the milk and cooked for thirty minutes in a double 
boiler. The same carbohydrate caloric value has been maintained ; the 
food has been given in the same amount and at the same interval. As 
a result of such changes I have many records showing a prompt and 
continuous gain. 

In many cases, every year, I use malt soup, starch, and milk cooked 



78 THE PRACTICE OF PEDIATRICS 

together because I am obliged to get results. I use the evaporated milks 
for the same reason. It is a fact also that a combination of evaporated 
milk, starch, and milk-sugar and bicarbonate of soda will be better 
utiUzed by very troublesome cases if they are cooked together. In like 
manner I use malt soup and starch with the evaporated milk. 

There is no doubt whatever that in troublesome feeding cases the 
heating of milk with an alkali and starch renders the milk easier of utiU- 
zation by the infant. Of course, the milk strength has to be carefully 
adjusted, and the feeding intervals and' quantities must be adapted 
to the age and weight of the child. Perhaps stomach washings will 
be required. In other words, the physician must possess judgment as 
to these matters. Not a little of the success attained in infant-feeding 
depends upon the experience and judgment of the physician. 

Frozen Milk. — During the past 30 years many thousand quarts of 
frozen milk have been fed to infants under my care. In no instance 
has it been demonstrated that frozen milk was the cause of illness. 
There is no reason for the belief that milk which has been frozen dis- 
agrees with the average bottle-fed baby. 

SCIENTIFIC INFANT-FEEDING 

I was recently taken to task by a young colleague for usmg evapor- 
ated milk, malt soup, dextromaltose, and various flours, such as barley 
and Imperial Granum, in feeding difficult cases. It was unscientific 
to use these substances, the argument maintained, because the human 
breast did not elaborate evaporated milk, malt soup, barley flour, or 
dextromaltose. Instead of such substances, fresh cow's milk, lime- 
water, milk-sugar (Squibb's), and boiled water should be employed. I 
replied that I had used the substances enumerated daily for twenty- 
five years and had fed several thousands of infants on fresh cow's milk, 
milk-sugar, and lime-water ; while in my experience with many nursing 
mothers in institutions and in private work I could not recall a single 
instance wherein the human breast had secreted fresh cow's, milk, lime- 
water, or Squibb's milk-sugar. 

Scientific infant-feeding consists in supplying a balanced ration offaty 
proteid, carbohydrate, and mineral salts in an assimilable form upovr 
which the infant makes normal development. Neither the fat, proteid, 
nor carbohydrate must be of one invariable form. Nature permits of 
a wide latitude. 

In function, moreover, the fat and carbohydrate are interchange- 
able and may vary widely in nature and in quantity. There must, 
however, be a fairly definite content of proteid of a nature that admits 
of its utilization ; or we shall have varying degrees of malnutrition and 
marasmus; for without nitrogen and other proteid constituents cell 
growth is impossible. By the use of starch and alkalis, the subjection 
of milk to the influence of heat of varying degrees, and by other means, 
we may change the nature of the proteid to such an extent that the in- 
fant may utilize the food in a manner before impossible. 



HABITUAL LOSS OF APPETITE 79 

Idiosyncrasy to Food Substances. — 'Food Allergy.— Children may 
show idiosyncrasy to various food substances. 

Dr. O. M. Schloss,* of New York, calls attention to a case that was 
sensitized to egg-white, oatmeal, and almonds to such degree that a 
cutaneous reaction occurred to these substances. Infants and young 
children may show this intolerance to any food containing protein. 
During the past 18 months I have tested 47 children who showed 
the cutaneous reaction and who were made ill when egg was given. 
Eleven of my patients showed a cutaneous reaction to milk, 9 reacted 
to oats, 16 to wheat, 9 to rye, and 10 to barley. A considerable experi- 
ence with cutaneous reaction to protein has shown some very contra- 
dictory findings. Children are not always made ill by a protein 
administered by the stomach that may produce a marked cutaneous 
reaction. Much remains to be learned of this very interesting subject. 

HABITUAL LOSS OF APPETITE 

The growing child, like the adult, not only requires sufficient 
nourishment to sustain life, but, in addition to this, an extra amount 
to supply the demands of growth. Proportionate to their size, 
therefore, all growing animals require more food than do those that 
have reached maturity. The young child is naturally such a very 
hungry animal that ample feeding is absolutely essential. There- 
fore, when there is habitual loss of appetite so that the child's entire 
life may be unfavorably influenced, we must realize that the condition 
is abnormal and strive to discover the cause and apply the remedy. 

Physicians are often consulted by parents whose children are suf- 
fering temporarily or persistently from loss of appetite — a condition 
usually associated with secondary anemia and asthenia. The child 
apparently is not ill : he may be active and playful, but he tires easily. 
The sleep ordinarily is sound and refreshing, but the child must be 
coaxed to eat. Oftentimes he will take food only when his attention 
is diverted by a story or a toy. He usually eats for the entire family, 
taking a mouthful each for father and mother, for the coachman, 
and for the cook! Three or four times a day, depending upon the 
number of meals, this coaxing, entertaining process has to be gone 
through. Occasionally children with habitually poor appetites 
for food in general will have a history of excessive milk-drinking. 
From 3 to 5 glasses of milk may be taken daily and all other food 
refused. When milk forms the principal or only article of nourish- 
ment after the eighteenth month, children will invariably show 
evidences of malnutrition. They are apt to be pale and sallow, with 
flabby muscles. The most frequent cause of loss or lack of appetite 
is too frequent feeding. It is not at all uncommon to see children 
from two to four years of age who are being fed six or seven times in 
twenty-four hours, the argument of the parents being that: ''The 
child takes so little food, he ought to take it oftener." With increas- 
* American Journal Diseases of Children, vol. iii, p. 341. 



80 THE PRACTICE OF PEDIATRICS 

ing age, more and stronger food is required at less frequent intervals. 
In other cases children may not get their regular feedings at such 
frequent intervals, but are generously supplied between meals with 
candy, cake, crackers, and fruits. Unsuitable food may be the cause 
of a habitually poor appetite. Children of tender age who are regularly 
fed from the adult table with heavy adult food, oftentimes improperly 
cooked, soon suffer from loss of appetite. Children who are poor 
eaters usually have the associated ailment, constipation. Too close 
confinement indoors is not infrequently associated with, if not a 
direct cause of, lack of appetite. Children who are kept uninter- 
ruptedly in the house for weeks at a time invariably have poor appetites. 

Treatment. — In order to emphasize a point in teaching, when 
treatment is under consideration, I have sometimes found it useful 
to state, first, what not to do. Do not give these children drugs as 
a means of inducing an appetite until all other means have failed. 
The only medication that should be permitted is some simple laxative. 
There must be one evacuation of the bowels daily. The aromatic 
fluid extract of cascara sagrada, from 1 to 2 drams, given daily at bed- 
time, or from 3 to 5 ounces of the citrate of magnesia given before 
breakfast, ordinarily answers well. 

Fresh Air. — Every '' runabout" child should spend at least five 
hours daily in the open air, regardless of the season of the year. Dur- 
ing very inclement weather in winter, indoor airing (see p. 760) is a 
most satisfactory substitute. 

Diet. — -An important step in the treatment is the regulation of 
the feeding hours. A child from twelve to fifteen months old requires 
five feedings daily (see Dietary, p. 105). Ordinarily, for ''runabout" 
children from the fifteenth to the twenty-fourth month, four meals 
daily are necessary, but when there is loss of appetite, three meals 
often answer best. After the second year, three meals are invariably 
the rule unless the child is weak or ill. All feedings should be given 
at a definite time each day, from which there should be no deviation. 
Nothing whatever except water should be allowed between meals. 
My next step, in case these regulations fail, is to place the child tem- 
porarily on a markedly reduced diet, no solid food, such as meat, eggs, 
breadstuffs, vegetables, or fruits, being allowed. Milk, gruels, and 
broths should comprise the nourishment. When the desire for food 
returns the regular feeding schedule is resumed. The mother must 
be given the directions both orally and in writing. 

If the case is one of milk habit, then the milk must be entirely cut 
off, and broth, thin gruel, dry bread, or zwieback substituted. The 
mother is instructed to return with the child in two days. In the 
great majority of instances the report after forty-eight hours is that 
the child is ravenously hungry. When such is the case freer feeding 
is allowed, but under the same strict observance of feeding intervals, 
with absolutely no feeding between meals. It is extremely rare to 
meet a case of habitual loss of appetite which will not respond to this 
simple method of treatment. In a large number of cases of failing 



SUBSTITUTES FOR STOMACH-FEEDING 81 

appetite I have succeeded in restoring the desire for food by removing 
milk largely from the diet, having it skimmed and given in small 
amounts, morning and evening, and in reducing the sugar intake to a 
minimum. Many children get more milk than is good for them, and 
practically all children get more sugar than they can utilize with 
benefit. 

Change of Climate. — Occasionally a child is brought for treatment 
who fails to show the least evidence of disease and yet will not respond 
to proper dietetic and hygienic measures. For such, a change of 
climate in addition to proper methods of feeding has been found ad- 
visable. A change from the city to the country, or from the inland 
country to the seashore, has been followed by a decided improvement. 
When such changes are impossible, or when proper dietetic regulations 
are impracticable, as with our dispensary patients, medication may 
be of service. 

Tonics. — In my experience the best medicinal means of improving 
the appetite is a solution of citrate of iron and quinin in sherry wine, 
1 grain of the citrate of iron and quinin being dissolved in }i dram 
of sherry wine and given, well diluted, before meals. This dosage 
will answer for children over eighteen months of age. For younger 
children, 3-^ grain of the citrate of iron and quinin in 3^^ dram of sherry 
wine, well diluted, may be given. If this is not successful, 1 minim 
of dilute hydrochloric acid, J^ minim of the tincture of nux vomica, 
and 2 teaspoonfuls of water may be given at two-hour intervals to 
children over fifteen months and under two years of age. After the 
second year 2 minims of the dilute hydrochloric acid and 1 minim 
of nux vomica, in 3 teaspoonfuls of water, may be given at two-hour 
intervals. 

There remain also to be considered under this head not a few 
children who habitually suffer from poor appetite and are below the 
average in every respect. This type of child is considered in detail 
under ''The Care of the Delicate Child" (p. 123). 

SUBSTITUTES FOR STOMACH-FEEDING 

In the management of the diseases of children conditions arise 
from time to time which necessitate the nourishment of the patient by 
channels other than the stomach. In persistent vomiting, when there 
is an acute involvement of the stomach, as in an acute gastro-enteric 
infection, in cyclic vomiting, and in vomiting due to some more 
remote cause, as meningitis or nephritis, the patient must receive 
water and food in order to sustain the system until the exciting factor 
is removed. 

Nutrition by means other than stomach-feeding may be necessary 
in retropharyngeal adenitis or abscess, in stricture of the esophagus, in 
diphtheria, in the exanthemata, and in pneumonia during the course of 
active delirium. A substitute for stomach-feeding is often useful in 
marasmus, in the generally delicate, and in those with reduced assimi- 
lative powers. Various means of substitute feeding have been at- 
6 



82 THE PRACTICE OF PEDIATRICS 

tempted from time to time. Nutritive suppositories have been advo- 
cated and proved failures, perhaps because of our inabihty to place 
them sufficiently high in the bowel. Placed in the rectum, they 
excite peristalsis and are expelled. 

Hypodermic Feeding. — Hypodermic feeding, and the introduction 
of food into the circulation are unsafe and impracticable in the treat- 
ment of children. 

Feeding by Inunction. — Feeding by means of oil inunctions, by 
active friction, or by the more passive means of wrapping the child in 
oil-soaked. cotton and allowing him to rest in it, is thought by many to 
be effective, in spite of the fact that the skin is an organ of excretion, 
and that its powers of absorption are very slight. I am convinced that, 
for infants and young children, the inunctions of properly selected oils 
possess distinct nutritive value, more benefit being derived by the pa- 
tient than can be attributed to the lubrication of the skin and the mas- 
sage. The rubbing of mercurial ointment into the skin is one of the 
most familiar means of introducing mercury into the circulation. No 
one will dispute the efficacy of this form of treatment. Fat inunctions 
are useful for marantic infants, and delicate "runabouts" with low fat- 
digestive capacity. In chronic diseases also, such as tuberculosis, 
syphilis, and rheumatism, oil inunctions are of advantage. They may 
be used with advantage during convalescence from the severe acute 
diseases, which have not only reduced the patient's weight, but have 
so affected the digestive and assimilative functions that a return to 
health is materially retarded. A brine bath (p. 780) should precede 
the inunctions, which are best given at bedtime. If possible, an 
animal fat should be used. Goose-oil and unsalted lard are preferred. 
Cod-liver oil is never advised on account of its very disagreeable odor. 
Olive oil may .be employed in case the unsalted lard or goose-oil is not 
obtainable. Cacao-butter is the least desirable of all fats that may be 
used for this purpose, particularly if the child is young and athreptic, 
for the reason that there may not be enough bodily heat to keep the oil 
fluid after it has been rubbed into the intercellular spaces and hair- 
follicles. For children under one year of age, it is my custom to direct 
that one-half ounce of goose-oil, unsalted lard, or olive oil be rubbed 
into the skin of the arms, thorax, legs, and back immediately following 
the salt bath. The rubbing is to be continued until the oil disappears, 
which may require from ten to fifteen minutes. The rubbing should be 
done with the palm of the hand and not with a brush or a cloth. In a 
few cases it is difficult to have the oil absorbed, even though not more 
than one dram is used. This condition is most common in those who 
most need the oil — athreptics with low temperature, in whom the 
superficial circulation is very poor. After the inunction the child 
should at once be put to bed. For older children, 3^^ to IJ^ ounces of 
the oil may be used. How much will be required for the ten to fifteen 
minutes' rubbing will soon be learned. In these cases, also, the in- 
unction should follow the brine bath. The use of the oil inunction in 
hundreds of cases has proved its efficacy. How much of the beneficial 



SUBSTITUTES FOR STOMACH- FEEDING 83 

effects are due to the oil as a food, how much to the massage, producing 
better skin action, improving the nutrition of muscles and inducing 
better sleep, I am unable to say. The beneficial effects of the inunction 
are probably due to three factors: the oil acts to a slight extent as a 
food, the massage increases the functional activity of the skin, and im- 
proves the muscle nutrition. 

Rectal and Colonic Feeding. — Any means of treatment which is 
disagreeable both to patients and attendants, and difficult of execution, 
is very liable to fall into disfavor unless pronounced beneficial results 
are the rule. While absolutely nothing can be promised so far as sup- 
plying nutrition by this means is concerned, careful observation and 
experience tell us that in a certain number of cases the measure is of 
much value. Whether the treatment will be of service in nourishing 
the patient can be determined by trial only. In children, particularly in 
very young children, on account of the ease with which peristalsis is 
excited, nutrition by this means is less frequently successful than in 
the adult. Nevertheless, it has been of material assistance to me in 
many a trying situation. Not a few of the failures are due to a lack 
of appreciation of the details of the procedure. Directions to mothers 




Fig. 7. — Hard-rubber piston syringe. 

or nurses to inject a certain quantity of some particular food, unless 
specific instructions are given, will usually be carried out as follows: 
A hard glass or rubber tip will be passed into the rectum from one to 
two inches. Through this the fluid will be forced. In a very few 
minutes, perhaps immediately, the bowel will empty itself into the 
napkin or bed-pan, the enema being of no service. This is what may 
be expected and what will happen when tHe child is given the nutrient 
enema in this way. The hard tip placed within the anal ring, and the 
fluid, are very apt to excite vigorous peristalsis. In order that the 
nourishment may be retained, it should be carried high up into the 
descending colon. The advantages of this method are two-fold: it is 
much better retained ; and, on account of the greater surface of mucous 
membrane with which it comes in contact, it will be quickly and more 
completely absorbed. 

How to Give a Nutrient Enema. — The nutrient enema is best given 
as follows: A soft-rubber catheter. No. 18 American, or a small rectal 
tube, adult size, is used, the former being preferred. The catheter or 
tube is slipped over the small tip of an ordinary fountain-syringe. The 
tube should not be too flexible nor yet too stiff. If too flexible, it folds 
readily on itself when the point meets' with any resistance, and the 



84 THE PRACTICE OF PEDIATRICS 

fluid escapes perhaps an inch or two within the anal opening. If the 
tube is too rigid or if force is employed, the mucous membrane and the 
parts may very easily be lacerated. 

The position of the child while the enema is being given is impor- 
tant. He should rest on his left side, preferably in the Sims' position, 
with the buttocks elevated to a plane at least four inches higher than the 
shoulders. A pillow or a folded blanket covered with a rubber sheet 
should always be available for this purpose if a bed-pan is not at hand. 
The child, if old enough to understand, is assured that no harm will 
come to him. With the patient in position and an assistant to hold 
him, the anus is covered with vaselin. It is not enough to oil the tube. 
The tube attached to a fountain-syringe is warmed and well oiled and 
passed into the rectum. The lower end of the bag should be three feet 
higher than the child's body. There may be some straining at first, 
but with the child in a proper position, one may pass a tube of the 
right degree of flexibility high into the intestine in a few seconds. The 
tube should be introduced about nine inches — far enough at least to be 
felt in the descending colon when the fluid is allowed to pass rapidly 
into the bowel. When the bag is emptied, the tube is rapidly with- 
drawn and the child, although allowed to change to the dorsal posi- 
tion, is encouraged to rest on his side. In any event, the buttocks 
must be kept elevated for at least one-half hour. In using small 
amounts of fluid it is well to allow for the quantity which may remain 
in the tube of the syringe and in the catheter after the enema is given. 
In managing older children, who exert much bearing-down or strain- 
ing, it may be necessary to attach the catheter to a Davidson syringe 
or to an ordinary rubber (Fig. 7) or glass piston-syringe of large size, 
in order to provide sufficient force to overcome the pressure exerted by 
the abdominal muscles. 

The nutriment should be neither too hot nor too cold. With 
either of these extremes, peristalsis is apt to be excited. I have found 
a temperature of 95 °F. to be the most satisfactory. If bowel action 
has been fairly free, previous washing with a normal salt solution is not 
necessary. If there has been no movement for six hours, it will be well 
first to use an irrigation of normal salt solution. Glycerin should not 
be used. The irrigation should precede the enema by from fifteen 
minutes to half an hour. 

Nourishment Not to he Used in the Rectum. — Oils or fats in any form, 
even though pancreatinized, should not be used. Alcohol should 
be used only in very urgent cases, and then it should be well diluted 
and used not oftener than once or twice in twenty-four hours. It has 
a decidedly irritant action on the intestinal mucous membrane and 
is not well retained. When used, it should be diluted with from 12 to 
16 parts of water or an equal quantity of skimmed milk, which has 
been peptonized or pancreatinized. In giving stimulants by the 
rectum, whisky is usually employed in quantities from one-fourth ounce 
for a child two years of age, to one ounce for a child from six to ten 
years of age. 



SUBSTITUTES FOR STOMACH-FEEDING 85 

Nourishment to he Used. — By far the best food for rectal alimenta- 
tion is skimmed milk completely pancreatinized. It is better retained 
and more completely assimilated than any other form of nutriment 
which we possess, as is shown by its results in maintaining the nutrition 
and strength of the patient. In cases in which it is desired that a con- 
siderable amount of fluid be absorbed by the intestine, the pancreatin- 
ized milk may be diluted with a normal salt solution. Where such milk 
is not available, the whites of three raw eggs, mixed with a normal salt 
solution, may be given. Not infrequently I order the whites of one or 
two raw eggs given in the pancreatinized skimmed milk, believing this 
combination gives us the best form of nutrient enema. The predigested 
proprietary preparations, the so-called ''peptones," have not been 
satisfactory in my hands. 

The amount of nourishment to be used at one time varies with the 
age and condition of the child. 

ORDINARY AMOUNT TO BE GIVEN IN ENEMA 

Under three months 2- 4 ounces 

From three to six months 4- 6 ounces 

From six to twenty-four months 6- 8 ounces 

After the twenty-fourth month ; 8-16 ounces 

Because the first enema is not retained, it does not follow that a 
second given immediately thereafter will share the same fate. In not 
a few instances, when I have given the second enema ten minutes after 
all or the greater part of the first had been expelled, the entire second 
amount has been retained. It is rarely wise to repeat the enema 
oftener than at six-hour intervals; and, when the intestine shows a 
tendency to intolerance, the intervals should be increased to eight or 
ten hours. 

This means of nutrition in children is of temporary use at best. 
The period of its application in the average case, even when tolerated 
at first, is only two or three days. In a few instances I have been able 
to use the method longer. 

Illustrative Cases. — During the summer of 1903 a very delicate three-months- 
old child under my care, weighing six pounds and ten ounces, retained two ounces 
of completely pancreatinized skimmed milk, given at six-hour intervals for three 
days, and three ounces at eight-hour intervals for eight days longer, making a 
period of eleven days in which the enemata were employed. Such tolerance of 
the large intestine, however, is very rare. 

In another case the use of enemata following an operation for intestinal ob- 
struction with protracted vomiting and prostration unquestionably saved a child's 
life. 

In a recent severe case of cyclic vomiting, which was seen in consultation, 
the vomiting had persisted for three days. This child was six years of age. He 
showed marked emaciation, and suffered from intense thirst; his pulse was weak 
and soft. A nutrient enema was given, composed of eight ounces of pancreatin- 
ized skimmed milk, eight ounces of normal salt solution, and the whites of two 
eggs. Not one drop was expelled. In one-half hour the boy claimed to feel 
better. The intense thirst was relieved and he fell into a restful sleep. In six 
hours the enema was repeated, about four ounces being expelled. This was fol- 
lowed by enemata at eight-hour intervals, eight ounces of the milk with the whites 
of two eggs being given, all of which was retained. At this point the vomiting 
abruptly ceased and further enemata were not required. 



86 THE PRACTICE OF PEDIATRICS 

DISORDERS OF NUTRITION 
MARASMUS (ATHREPSIA; INFANTILE ATROPHY) 

Under the title of marasmus will be considered those cases which 
are associated with and dependent upon derangement of function of 
the gastro-enteric tract. Tuberculosis, syphilis, and atelectasis are 
consequently excluded, these affections being considered elsewhere 
under their respective headings. 

Age. — Marasmus is seen most frequently in young infants under 
nine months of age. Cases are frequently seen, however, from the 
ninth to the twelfth month, and comparatively few between the 
twelfth and eighteenth months. 

Pathology. — There is no lesion or set of lesions peculiar to infantile 
atrophy. I have personally autopsied a large number of cases. There 
is often a strip of hypostatic pneumonia, perhaps a large area of atelec- 
tasis. Now and then the liver is fatty or shows fatty areas. The 
spleen, kidneys, and heart are pale. The stomach and intestines con- 
tain thick, sticky mucus, which when removed shows a pale, washed- 
out-appearing mucous membrane. Blood infections with the pyogenic 
cocci have explained the etiology in several recent cases. 

Etiology. — A great deal of research work has been done among 
marasmic infants in order to determine the nature of the condition, 
but as yet no satisfactory explanation has been offered. The disease 
is unquestionably due to defective intestinal assimilation. . The prin- 
cipal fact that disproves the existence of any atrophic condition or 
any necessarily severe derangement of function is that these patients 
very often make complete recoveries, becoming perfectly normal chil- 
dren after three months or more of treatment. 

The Usual History. — The history of these cases is as follows: The 
mother could not or did not nurse the baby. The child was put on 
cow's milk, which was usually given too strong or in too large quanti- 
ties — oftentimes both errors were combined, or the milk may have been 
too old when used, and improperly cared for; in any case the milk 
disagreed, the child was made ill, there was loss in weight, cow's milk 
was discontinued, and one of the infant foods, alone or combined with 
milk, was given; but the child's digestion being thoroughly disordered, 
the foods failed to agree. There was vomiting or regurgitation, with 
undigested, green stools, or both combined, while the loss in weight 
continued. The child may have been inherently weak or may have 
shown a cow's-milk idiosyncrasy to help account for the lack of success 
in the milk-feeding. Usually there followed a series of experiments 
with different kinds of food and methods of feeding, the vomiting, 
diarrhea, or colic continued with wasting, and when the child reached 
the hospital or office he was perhaps six months of age and weighed 
from 6 to 9 pounds, presenting a typical athreptic picture. Some of 
these children are born with a digestion that is apparently incompati- 
ble with cow's-milk mixtures. Others have their digestive capacity 
for cow's milk hopelessly deranged by improper feeding methods. The 



MARASMUS (aTHREPSIA; INFANTILE ATROPHy) 87 

majority of the cases occur among the overcrowded tenement poor — 
the worst possible environment for a dehcate infant. There is httle 
or no proteid assimilation, so that any approximation to normal growth 
is impossible. They may also possess a poor fat capacity, and if there 
is, in addition, a diminished sugar capacity the proteids of the tissues 
are drawn upon to supply heat and energy, with resulting progressive 
emaciation. Heredity, environment, and the season of the year all 
influence the prognosis. 

Infection as a Contributing Factor in Marasmus. — In om' manage- 
ment of athreptics we have been so occupied with nutrition and the 
gartro-intestinal tract, that other possible etiologic agencies may have 
been neglected. Occult infections may and do play a very decided part 
in some of these cases. Thus during a recent service at the Babies' 
Hospital, out of 17 cases in which blood cultures were made, 5 were 
positive, and of these 5 infants, 4 died. Of the remaining 12 negative 
cases, 8 died, and of the 4 that recovered 1 had an otitis; and 1, a 
furunculosis of mild degree, while the remaining 2 had no demonstrable 
lesions. Of the 8 fatal cases, there were only 2 in which there was no 
evident infection. The infection varied from an otitis to a severe 
bronchopneumonia. 

The blood cultures in each case were taken when the infant was 
losing in weight and apparently retrogressing without any digestive 
disturbances. In two instances the clinical evidence (if it might be 
called such) was manifested by a subnormal temperature, well-digested 
stools, and progressive loss in weight. In two others there existed a 
temperature and later signs of a bronchopneumonia, while a third 
showed Klebs-Loffler bacilli in the nose. Blood counts were of no aid 
in diagnosis. 

Marasmic infants who fail to thrive on suitable food and good gen- 
eral management, whether there are evident digestive disturbances or 
not, should be thoroughly examined for hidden infections. In not a 
few of those who show progressive loss in weight there has been a sup- 
purative otitis without active symptoms. In others there has been a 
bacteremia, the only symptom being that of progressive loss in weight. 

Pyloric Obstruction as a Cause of Marasmus. — During the past 
three years twenty-four infants have been seen by me, showing, nearly 
all of them extreme malnutrition. They gave a history of vomiting, 
usually beginning in the second or third week and the vomiting con- 
tinued daily with marked loss of weight, constipation and no fever. 
Thorough examination showed that these cases had either pyloric 
stenosis or spasm of the pylorus, or both. All malnutrition infants 
with persistent vomiting should be examined and observed to deter- 
mine whether or not there is trouble at the pyloric outlet. 

Treatment. — An important determining factor as to the child's 
future depends upon whether or not he can have the advantage of a 
wet-nurse. That a great majority of the cases of simple athrepsia re- 
cover, and often recover promptly, making a most satisfactory growth, 
when a wet-nurse is secured, is proof, as above stated, that the condi- 



88 THE PRACTICE OF PEDIATRICS 

tion, SO far as relates to any peculiar systemic state or pathologic con- 
dition, depends more upon the nature of the nutrition than upon the 
patient. In securing a wet-nurse the physician's duties are by no 
means completed. The patient may not take kindly to the breast, and 
will have to be taught breast-nursing. A great deal of time may be re- 
quired in teaching older infants, those who have been on the bottle for 
seven or eight months. To this end, various devices may have to be 
used. For the first nursing it is well to allow the child to go for an hour 
or two beyond the feeding-time in order that his appetite may be 
voracious. It is advisable also to give the first few nursings in a dark- 
ened room with the person who has been accustomed to feeding the 
patient very near. Sufficient milk should be forced from the breast to 
enable the child to taste it. A little powdered sugar sprinkled on the 
nipple is a good means of increasing his interest. In some instances 
it has been necessary to cover the wet-nurse with a blanket or sheet, 
leaving only the breasts exposed; or it may be necessary to use the 
nipple-shield for a few days in order gradually to accustom the child 
to the change. I have yet to see a case in which success did not follow 
persistent effort. Oftentimes the nurse's milk will not agree at first; 
but this is not surprising and need cause no discouragement. Breast- 
milk ordinarily is a much stronger food than the child has been accus- 
tomed to, and it may produce vomiting, colic, or diarrhea. When 
indigestion follows, the nurse's milk should be modified by giving the 
baby weak barley-water or plain boiled water, before the nursing in 
case he nurses well, or after the nursing in case he nurses poorly. One 
or two ounces of breast-milk at a feeding is all that these patients can 
be expected to take during the first few days. The amount obtained 
may readily be determined by weighing the patient, without the 
trouble of undressing him, before the nursing, and then weighing him 
at intervals of from three to five minutes after the nursing has com- 
menced. An ounce of breast-milk is practically an ounce avoirdupois. 
These children, if not too weak, will take greedily almost anything 
from the bottle. The addition of an ounce or two of barley-water or 
plain water dilutes the milk and renders it easier of digestion, and 
furnishes at the same time the necessary fluid for the child. The 
most unpromising cases of marasmus are not to be despaired of nor the 
treatment relaxed, although the physician should be cautious in his 
prognosis. If the child is too weak or indifferent to swallow, the wet- 
nurse's milk may be expressed, diluted, and given by gavage. In many 
cases evaporated milk (see p. 95) may be used successfully for maran- 
tic infants. It is much easier of digestion than fresh cow's milk, and 
is a temporary measure of much value. 

Hospitals and institutions for .children always carry a certain 
number of these unpromising cases. It is not infrequent to find miliary 
tuberculosis at autopsy where it was not suspected during life, no 
clinical signs of fever having been present. 

Illustrative Case. — The most pronounced and the most hopeless recovery case 
coming under my observation was seen by me in consultation in one of the suburbs 



MARASMUS (aTHREPSIA; INFANTILE ATROPHY) 89 

of New York. The child was four months old and weighed o pounds. He was 
emaciated to a skeleton, having weighed 8 pounds at birth. The temperature for 
several days ranged between 92° and 94°F, A trained nurse and an unusually 
intelligent mother were in charge. I doubted the accuracy of the thermometer read- 
ing, and different thermometers were used. The temperature was taken by the 
rectum. I took the temperature on one or two occasions with my own ther- 
mometer and found the reading correct. The attending physician had also taken 
it repeatedly, so that finally there was no doubt. The child was too weak to nurse. 
The breasts were accordingly pumped, and for each feeding he was given one-half 
ounce of breast-milk with an ounce of barley-water, to which a few drops of sherry 
wine were added. This w^as given by gavage at two-hour intervals. He was 
wrapped in flannel and wool and surrounded with hot-water bottles. The food 
was retained and digested. In four days he could nurse, and was allowed to take 
a small amount from the breast and finish the meal with barley-water. The tem- 
perature gradually rose to the normal. More breast-milk was allowed as he 
proved able to care for it, and the child made a perfect recovery, weighing 18 pounds 
when he was nine months old. 

This case demonstrated to me that a marasmic child is never a 
hopeless case until he ceases to live. Unfortunately, very few marantic 
children can have the benefit of a wet-nurse, but without a wet-nurse 
many of these cases are not hopeless. The use of condensed milk 
(p. 95) and malt soup (p. 94) will furnish a satisfying diet in not a 
few cases. The condition is, of course, a very serious one, but the 
chances are much better in a reasonably good home than in a hospital, 
where the story is often as follows: The patients take the modified 
milk or whatever is given them without inconvenience. The stools 
may be offensive if cow's milk is given, or there may be constipation, or 
the stools may appear perfectly normal. As a rule, there is no serious 
diarrhea or an}^ other evidence of an acute inflammatory process in the 
intestine. However, in spite of fairly normal stools, the patient grows 
thinner and thinner. After a time all food is refused, gavage is used 
as a last resort, and the child finally dies. The autopsy shows nothing 
but pale organs, with perhaps a strip of hypostatic pneumonia. Now 
and then one of these cases in a children's institution or in a hospital 
recovers without a wet-nurse, but it is the exception proving the rule. 
Put these athreptics on a wet-nurse, as I do at every opportunity^ and 
many of them thrive in spite of the well-known unfavorable influence 
exerted by institutional life upon the very young. In addition to 
putting the athreptic baby on the wet-nurse, his stomach should be 
washed once daily and he should live out-of-doors. 

Outdoor Life. — Next to the wet-nurse, I know of no agent fraught 
with so much good as is outdoor life. The season of the year exerts 
considerable influence of the prognosis. The athreptic bears the heat 
and humidity very badly, and the early summer mortality of all large 
cities is materially increased by these children, who wilt and die in 
institutions and tenements with the first two or three days of continu- 
ous hot weather. Parents residing in a large city who can so afford 
should send such children to the country not later than June 1st, to 
return, in this latitude (New York Citj^j not earlier than October 1st. 
During the day the child should be on a porch or in the shade con- 
tinuously. At night the windows of his sleeping-room should be wide 
open. During the cooler months if the child is too ill to be taken out 
of doors he should have from morning until evening a continuous in- 



90 THE PRACTICE OF PEDIATRICS 

door airing (p. 20). The sleeping-room should always communicate 
with the open air. The roof-garden in large cities is a most valuable 
aid in the management of athreptic children. 

Cases in Which a Wet-nurse Is Impossible. — While much has 
already been said about this most interesting and important subject, 
one phase has not been touched upon. I refer to the athreptic infant 
of the tenement, and those others in private life for whom a wet-nurse 
is impossible. They furnish by far the largest number of our marasmic 
patients. Perhaps the most frequent error in the management of these 
cases is an endeavor to select at the start a food for the child to thrive 
upon. In doing this, almost invariably a stronger food is selected than 
the child is capable of digesting, and he is made worse by the attempt. 
Our ultimate object in treating these infants will be more readily 
attained if, at first, we attempt only to supply a food upon which they 
can exist without loss in weight. The number of calories necessary 
for an athreptic child is not great. It must be remembered, further- 
more, that we are not dealing with a case of infant-feeding as the term 
is commonly understood. True, we are feeding an infant, but a sick 
infant, and the methods of feeding used for the comparatively welt 
do not apply here in all respects. The problem of nourishing these 
children is to be considered from two standpoints — that of the food 
and that of the baby, with special reference to the organs of digestion. 
The stomach, in many of these infants, is dilated, with a consequent 
lack of motility. Residual undigested food remains long after feeding. 
There has been a constant fermentative change, with the production 
of lactic and butyric acids, resulting in local changes of an inflamma- 
tory nature in the mucous membrane of the stomach, so that not only 
must the organ be prepared for the food, but the food must be adapted 
to the stomach capacity, and when this is done, — when both require- 
ments receive due consideration, — we are much more likely to succeed. 

Stomach-washing. — In all of these cases, for the first few days of 
treatment, I wash out the stomach with sterile water, regardless of the 
presence of vomiting and regurgitation and regardless as to whether the 
child is bottle-fed or breast-fed. It is often surprising to note the 
amount of thick mucus and undigested food that will be washed from a 
stomach from which there has never been vomiting. The daily wash- 
ings enable the child to take more food and stronger food. It may be 
necessary to continue the washings for days. They may first be dis- 
continued when the water siphons clear and without mucus. They 
should be repeated if there are indications, such as regurgitation of 
sour water or mucus or loss of appetite. In a case seen recently in 
which there was chronic gastritis with athrepsia, washings were 
continued at gradually lengthened intervals for six months. 

Feeding. — If the case is one with pronounced stomach involve- 
ment, a 3 per cent, milk-sugar solution is given for twenty-four hours in 
quantity suitable for the age and size of the patient. The following 
day barley-water No. 1 (see formulary, p. 70) is given, to which sugar 
is added to make the mixture 5 per cent. 



MARASMUS (aTHREPSIA; INFANTILE ATROPHY) 91 

Cow 's Milk, — While it is doubtful if the child can take cow^s milk 
after this period of stomach-rest and stomach-washing, it may be at- 
tempted. Two drams of as safe milk as can be obtained are added to 
every second feeding of the barley and sugar water. If it agrees, after 
a day or two, two drams are added to each feeding, with a gradual 
increase of a dram every two or three days. The intervals of feeding, 
for children under one year of age, may range from two to three hours. 
It is rarely advisable to feed even the most delicate athreptic oftener 
than once in two hours. If the milk can be retained and assimilated 
in the strength of one-fourth milk and three-fourths barley with 5 per 
cent, sugar, or if an equal quantity of milk and sugar-water alone is 
found to agree, the child will begin to grow and general improvement 
will rapidly follow. If the cow's milk is not well borne, skimmed milk 
or a weak cream mixture — one-half dram of cream to a feeding — 
may be tried. It is practically impossible to have whey made properly 
outside of a hospital laboratory or an intelligent home. In using whey 
it may be given in quantities suitable to the age of the patient. The 
prescribing of cream among the poor is a hazardous procedure, for the 
cream may be old, improperly cared for, and swarming with bacteria. 
If there is a tendency to looseness of the bowels, the diarrhea is thus 
made worse. Cream mixtures rarely succeed as foods for athreptic 
children. I use cream only among those who can properly care for it. 
The Peerless Brand (Borden) (p. 96), evaporated and unsweetened, 
may, however, often be used with success. 

Sweetened Condensed Milk. — I have found that for the out-patient 
athreptic and for some in better circumstances the much-abused 
condensed milk fulfils a useful function. It is the cleanest food we 
can give the dispensary baby. It is the cheapest, the most easily 
kept, and the most easily digested milk that can be furnished him. 
Consequently, when ordinary milk feeding is impracticable or when 
it disagrees, I give condensed milk, beginning with one-half dram, 
which is added to the barley-water or to the plain water for every 
second feeding, later to every feeding, increasing the quantity gradu- 
ally as the child shows an ability to digest it. The patient must be 
seen frequently and the stools carefully examined in order that an 
increase in the food strength may be made as soon as conditions allow. 
The mother is told to bring the napkins to the dispensary, and the 
child is weighed at each visit, every second day. It is most gratifying 
to see how well some of them gain in weight, not because they are 
getting an ideal food by any means, but because the food used tem- 
porarily fits the case. Condensed milk is thus used as a stepping- 
stone to something better. When the child has taken condensed 
milk with benefit for a month or six weeks, ordinary milk is attempted 
if the time of the year is between October and the following June. 
After June 1st I continue with condensed milk, as the possibility of 
some degree of anemia and rachitis as the cooler months approach 
is to be preferred to the risk of attempting cow's-milk feeding, with 
poor milk, in the hands of overworked or ignorant mothers. 



92 THE PRACTICE OF PEDIATRICS 

In beginning ordinary milk, in order to avoid sudden radical 
changes I replace one feeding of the condensed-milk mixture daily 
with one feeding of a weak plain milk mixture. In some cases this 
will produce illness and must be stopped; in others, it will be well 
borne. When it is found to agree, two feedings should replace two 
condensed-milk feedings daily. In this way, by increasing by one the 
number of plain-milk feedings every third or fourth day, entire plain- 
milk feeding may safely be inaugurated. The strength of the plain 
milk should not, of course, correspond to that suggested for well 
babies. To a child of six months a three-months' formula may be 
given. As the child improves, the strength of the milk may corre- 
spondingly be increased. In this way I have treated successfully a 
great many tenement athreptics. 

Some children will be able to take and properly care for only two 
plain-milk feedings daily; others will take every second feeding of 
plain milk. I have a patient at the present time, aged fourteen 
months. He will take two plain-milk feedings daily with comfort, 
but when the third is given he is invariably made ill. Some will not 
be able to take a particle of ordinary milk. When this is the case, the 
condensed milk should be combined with a gruel, such as oatmeal, 
which contains a high percentage of proteid. These cases may also 
be given beef -juice at a very early age. I often use pure cod-liver oil, 
from 15 to 30 drops of which may usually be taken three times daily 
without disturbance. The tenement athreptic is given the benefit 
of as much fresh air as possible. He is also given the advantage of 
the daily tub-bath and the oil rub. For further suggestions, see 
difficult feeding cases (p. 94). 

MALNUTRITION IN INFANTS 

I am often asked by students the difference between malnutrition 
and marasmus in infants. While hard-and-fast lines cannot be 
drawn to indicate where malnutrition ends and marasmus begins, 
there is a vast difference between the two conditions. 

Etiology. — Malnutrition may best be described as the first stage 
of marasmus. Every child with marasmus must first have undergone 
a longer or shorter period of malnutrition. Victims through in- 
heritance, such as those who are constitutionally rheumatic, the 
offspring of the tuberculous, and the remotely syphilitic, often show 
signs of malnutrition. They are inherently weak, and possess low 
vital resistance. Frequent child-bearing may be a predisposing factor 
— the fourth or fifth child, when the pregnancies have been close 
together, may show general lack of vigor. 

Symptoms. — With malnutrition the infant may be three or four 
pounds under weight, his gain being slow and irregular; often inap- 
preciable, or, at best, a few ounces a week. The muscles are soft, 
and if the condition persists, bone changes, indicating rachitis, soon 
appear. The child is pale and usually thin. There is a secondary 



MALNUTRITION IN INFANTS 93 

anemia. Dentition is delayed. The hands and feet are apt to be 
cold, and the skin is dry. Excoriations of the buttocks and intertrigo 
are of common occurrence. The patient shows evidence of indiges- 
tion by a distended abdomen and stools that are far from the normal. 
There may, however, be no intestinal derangement whatever, the 
malnutrition being due to the fact that the child's diet for months 
has consisted of food that did not contain the nutritional elements 
required, or the fact that he was unable to utilize that which had been 
given him. 

A case due to high fat feeding was recently seen by me. The 
patient was a male, six months of age, weighing 13 pounds, a resident 
of a New York suburb, where the conditions are most healthful. 
His fontanel was slightly depressed, the muscles were soft and flabby, 
and the ribs were beaded. The child had lost his appetite and suf- 
fered from constipation. A history of the feeding showed that he 
had been getting a cow's-milk mixture containing approximately 6 
per cent, fat, 4 per cent, sugar, and 2 per cent, proteid. In this patient 
the indigestion, loss of appetite, and constipation was unquestionably 
due to the high percentage of fat. The energy exerted in digesting 
the food almost counterbalanced the benefit derived from it, the result 
being a very slow gain in weight. 

Diagnosis. — Upon assuming the care of one of these infants, one 
must invariably make a very thorough examination in order to de- 
termine whether there are other factors than that of imperfect gastro- 
intestinal function. Following the usual physical examination, which 
should include the ears, the urine should be examined; there should be 
a von Pirquet test for possible tuberculosis; there should be a blood 
count to learn the degree of anemia and the possibilities of occult pus, 
and if the case is very persistent, a blood culture should be made, as 
it not infrequently occurs that a hitherto unsuspected cause of mal- 
nutrition may be bacteremia. In my hospital cases the pneumococcus, 
the streptococcus, and the staphylococcus have been found in the 
blood in malnutrition babies. 

Treatment. — Diet. — The management of malnutrition due to such 
causes consists in correcting the digestive errors, in using castor oil 
or calomel with stomach- washing, and in adjusting the food to the 
child's requirements and digestive capacity. 

These cases are all difficult to feed satisfactorily. 
"The problem which confronts us is often most difficult of solution. 

Chapin is an advocate of the use of cereal gruel as a milk diluent, 
claiming that the milk is rendered more easily digested because of the 
presence of the starch. Others believe that the use of alkalis and ant- 
acids renders the milk easier of digestion. Personally, I have had very 
little success in fitting such special modifications of fresh cow's milk to 
difficult cases. In very few of these difficult cases that come to me do 
the ordinary cow's-milk dilutions and adaptations produce satisfactory 
results. The majority are infants who cannot digest cow's milk unless 
it is materially changed by other than mechanical methods. It is also 



94 THE PRACTICE OF PEDIATRICS 

to be remembered that in difl&cult feeding the food is only a part of our 
troubles. The physical condition of the child, his care, and particu- 
larly the containing and working capacity of the stomach, are matters 
requiring thought and adjustment. Our duties do not end with a 
change or series of changes in food. 
A difficult feeding case requires : 

1. Fresh air. Indoor airing in winter or roof treatment — cold air. 

2. Clothing sufficient to insure warmth; particularly must the 
extremities never be cold. 

3. Quiet — absence of handling other than is necessary for clean- 
liness. Quiet is particularly necessary if there is a tendency to re- 
gurgitation or vomiting. 

4. Stomach washing — a most useful procedure, even when there is 
no vomiting. A stomach lavage cleans out the mucus and undigested 
material from the stomach, which is very apt to be enlarged and of de- 
fective motility. The lavage may be used daily for a week, or less fre- 
quently — perhaps every other day. ^ In some cases one or two washings 
suffice. In others lavage is continued at intervals determined by 
the condition — rarely longer than three to four weeks. 

5. Position. In the cases with habitual regurgitation the position 
in which the child rests in the crib is important. Smith and Le Wald* — 
as a result of six Roentgen ray studies of infants after feeding — advise 
the erect position after feeding, the child being held against the nurse 's 
shoulder for a few moments. When the child is placed in the prone 
position, the head of the crib should be considerably elevated. Both 
of these proceedings aid in the expulsion of gas, which they proved 
is swallowed during the act of nursing. 

Milk. — The various forms of so-called peptonizing processes have 
obtained very little success in my hands, and I rarely employ this means 
and do not advise it. 

The methods that have been useful in nourishing these infants are 
as follows : 

Whey Feeding. — In some cases the feeding of whey (p. 71) may 
be of service. This means is not of very general application, as a 
milk laboratory or a very competent nurse is required to prepare the 
whey. 

Malt-soup Feeding. — The use of malt soup for infants after the 
fourth month is of much value in treating malnutrition and marasmus. 
For very young infants, also, malt-soup feeding is occasionally appli- 
cable, although the feeding of children before the third month by this 
method will result in more failures than successes. 

Contraindications to the use of malt-soup feeding at any age are 
vomiting and a tendency to looseness of the bowels. A considerable 
part of the digestive ailments of the very young include vomiting, so 
that this symptom must be controlled before malt-soup feeding is 
attempted. In feeding an infant under ten weeks of age in whom 
vomiting is not a symptom we may occasionally use malt soup with 
* American Journal Diseases of Children, vol. ix, pp. 261-282. 



MALNUTRITION IN INFANTS 95 

success. The patient most benefited by this feeding is the infant after 
the third month who is not actively ill, but who fails to thrive or who 
is made actively ill by the use of the ordinary milk modifications. 

I have had many children brought to me who had been carefully 
fed on modified cow's milk, in whom the milk had produced some 
disorder, such as colic, vomiting, or constipation. Such children very 
frequently appear comfortable and take the food eagerly, but make 
little or no gain in weight and do not thrive. They are pale, thin, 
sleep poorly, and are underweight two to five pounds. I have in 
hundreds of cases used the identical milk formula which the child was 
getting, and simply replaced the sugar of milk or the cereal flour which 
furnished the carbohydrate by malt-soup extract and some flour prepa- 
ration, with the resulting prompt response of a gain in weight of four to 
eight ounces weekly, although there had been a standstill for weeks. 

It is impossible to advise any definite milk strength in these cases, 
as the condition to be treated is abnormal, and wide variations in 
milk strength may be necessary. In general, the physician may select 
a milk formula which he considers applicable to the patient's weight 
and condition, and then, instead of using cereals or milk-sugar, use the 
malt-soup extract after the following manner. We may suppose that 
10 ounces full milk daily is to be prescribed. The formula will read 
as follows: 

10 ounces milk. 

20 ounces water. 

IJ-^ tablespoonfuls barley flour (Cereo or Robinson's). 

1 tablespoonful malt-soup extract. 

The amount and feeding intervals are the same as for other methods 
of feeding. The barley is mixed with the milk ; the malt mixed with the 
water. Both mixtures are stirred well together, placed in a double 
boiler, and allowed to simmer (kept under a boil) for thirty minutes. 
During the cooking process the mixture should be stirred frequently. 
At the completion of the cooking, water previously boiled is added to 
make the mixture 30 ounces. This is strained through a coarse-meshed 
strainer, and is then ready for use. 

If the child shows a tendency to vomit the food, the malt may be 
reduced one-half temporarily, or skimmed milk may be employed. 
When skimmed milk is used, from two to four ounces more should be 
added to the daily supply of food in order to make up to the child the 
loss of nutrition entailed by removal of the cream. As the food is 
found to agree, the milk strength may be gradually increased. 

Condensed Milk. — A satisfactory method of starting difficult feed- 
ing cases toward recovery consists in the use of condensed or evaporated 
milk. 

Condensed milk is in the market in three forms — fresh condensed 
milk sold in bulk, condensed milk to which cane-sugar is added, sold 
in hermetically sealed cans, and evaporated milk without the addition 
of sugar, sold in hermetically sealed cans. The best known and most 



96 THE PRACTICE OI PEDIATRICS 

readily available brands are Borden's condensed milk, known as the 
Eagle brand, and Borden's evaporated milk, known as the Peerless 
brand. The Eagle brand contains cane-sugar in considerable amount, 
and is rarely used. The Peerless brand is evaporated milk without the 
addition of sugar. In the condensing process the milk is heated to 
200°F. It is then transferred to vacuum pans, where it is maintained 
at a temperature of 125°F. until sufficient water is evaporated to bring 
the product to the required condensation. 

The analysis of the Eagle brand is as follows: 

Fat 9.5 per cent. 

Sugar 54.67 " '' 

Total proteid 7.84 " - " 

Ash 1.68 " " 

Water 27.31 " " 

The analyses of Peerless brand evaporated milk and the unsweetened 
condensed milk sold in bulk are very similar. The standard main- 
tained is as follows: 

Fat 8.3 per cent. 

Sugar 1€.05 " 

Proteid 7.1 '' 

Ash 1.43 '' 

Water 73.12 '* " 

In using condensed milk for feeding, that known on the market as 
evaporated milk should be used. In using this variety it must be re- 
membered that a fresh can must be opened daily. The fact that this 
milk is free from added sugar makes possible the feeding of a larger 
amount. One part of the milk to three, five, six, or more parts of 
diluent may be used. Thus, the formula for a day's food would read 
like the following: 

7 ounces evaporated milk. 

28 ounces water. 

, , J , / starch \ / starch, 

carbohydrate i r i ix ^ x 

•^ I sugar J I malt-soup extract. 

10 grains bicarbonate of soda. 

Milk of this strength affords a nutritional value of 1.66 per cent, fat, 
1.43 per cent, proteid, 2.01 per cent, sugar. To this mixture carbo- 
hydrate in the form of starch, cane-sugar, dextromaltose, milk-sugar, 
or malt-soup extract may be added to raise the total carbohydrate to 
6 or 7 per cent. If malt soup and starch are used, cooking will be re- 
quired. (See Malt-soup Feeding, p. 94.) More or less of the 
evaporated milk may be used as may be required. Many infants 
of very weak digestion will thrive on the evaporated milk thus given 
when all other artificial methods fail. To the very yo.ung, and those 
with poor digestive capacity, and to athreptics, a lesser amount of 
milk may be given at first, — one part of milk to seven or eight of diluent, 
— the quantity being increased as the infant shows improved capacity. 

As the child grows older and increases in weight the amount of 
evaporated milk may ,be increased. I have never given a stronger 



MALNUTRITION IN INFANTS 



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98 THE PRACTICE OF PEDIATRICS 

formula than 14 ounces of the evaporated milk (Peerless brand), 26 
ounces water, carbohydrate to 6 or 7 per cent. The weight chart (see 
Fig. 8) shows the progress made by a child on this scheme of feeding. 
Notes on the chart indicate when the evaporated milk feeding was 
begun and the various strengths used. Previously the child had been 
given various fresh cow's milk formulas. 

In not a few cases the food will be better assimilated if the entire 
mixture — milk, starch, sugar, and soda — is kept just under the boiling- 
point in a double boiler for thirty minutes. Occasional stirring is 
necessary, and at the completion of the heating process water should 
be added to bring the food to the original amount. 

Plain Milk. — When the child has remained comfortable for six to 
eight weeks or longer on such feeding, almost always with a gain 
in weight, one feeding daily of a plain milk mixture may replace a feed- 
ing of condensed milk. A raw milk mixture should always be given 
in weaker strength than the child's age calls for. In spite of the 
dilution it may occasion indigestion, colic, and the passage of curds. 
In such an event the condensed milk and its diluent must again be the 
sole diet for two or three weeks, when the use of ordinary milk may again 
be attempted. After a few days or a week, in case one such feeding 
is taken without inconvenience, a second feeding may replace another 
condensed milk feeding. In this way the number of plain milk feed- 
ings may be gradually increased until the child is taking a rational 
diet of this milk alone. A six-months '-old baby took daily three feed- 
ings of condensed milk and three of raw milk. Attempts were made 
to give him the fourth feeding of raw milk, but invariably with dis- 
astrous results. He was slightly under weight, but in a fair general 
condition. 

I have successfully managed a great many of these difficult feeding 
infants, as described above, withholding ordinary milk feeding until the 
child is taking the condensed milk well and gaining, then gradually 
advancing the raw milk feeding until, when the child is five or six 
months old, he will be taking daily and assimilating two or three feed- 
ings of the fresh milk. When six months old, and sometimes earlier, 
he may be given suitable raw milk feedings exclusively. I have found 
that by the above method the desired end of complete plain milk 
feeding is reached sooner than when small quantities of cow's milk 
are added to the condensed milk mixture. 

In beginning, it is best to give the raw milk at the first or second 
feeding in the morning, when the digestive powers are stronger than 
they are later in the day. When the second raw milk feeding is given, 
it should never immediately follow the first. The raw milk and the 
condensed milk should be alternated until more than one-half of the 
daily feedings are of fresh milk. 

Idiosyncrasies to Cow's Milk. — In rare instances cases are en- 
countered in which there exists an intolerance of cow's milk or any 
form of food which contains cow's milk, including condensed milk and 
all the malted foods containing desiccated cow's milk. In such cases 



MALNUTRITION IN INFANTS 99 

the use of any of these substances as foods produces illness of such an 
alarming type as to necessitate prompt discontinuance of the food. 
The only hope for infants thus constituted is a wet-nurse. 

Illustrative Cases. — An illustration of allergy to milk foods occurred in my own 
family. A healthy, full-term female infant whose birth-weight was 7 pounds 12 
ounces was nursed by her mother with indifferent success for two weeks, when the 
supply failed absolutely. Feeding with a most carefully prepared modified cow's 
milk was begun. The child refused the food, and tw^o drams were forced. This 
was followed, in a few moments,_ by vomiting and retching, which continued at 
intervals for twenty-four hours, with collapse and exhaustion to an extreme degree. 
A wet-nurse was secured, the breast was well taken, and the milk agreed perfectly. 
In three days the wet-nurse's milk began to fail and was entirely lost in twenty-four 
hours. A weak dilution of condensed milk was then given, with results almost as 
disastrous as before. The child at this time weighed 6 pounds 4 ounces, and 
showed all the symptoms of early marasmus. A second wet-nurse was secured 
whose milk also failed in a few days. Before her departure, however, a third nurse 
was engaged, on whose milk the child thrived most satisfactorily. When the 
patient was three months of age a weak cow's-milk mixture, prepared by the 
Walker-Gordon Laboratory, was given. The child refused the food, and one-half 
ounce was forced. As on the previous occasion, vomiting with prostration border- 
ing on collapse was the outcome. The child vomited at frequent intervals for 
twelve hours, and the breast was refused for twelve hours longer. The giving of 
cow's milk was not again attempted until the child was nine months old, a wet- 
nurse meanwhile being employed. The child was then strong and vigorous, and 
weighed 18 pounds. Two drams of cow's-milk mixture suitable for a child three 
months of age were given. This produced_ nausea and vomiting, as though an 
equal quantity of syrup of ipecac had been given, but no more serious disturbance. 
At this time the wet-nurse's milk began to fail. The breast-milk nutrition was 
assisted by the use of a cereal made into a thick gruel. Oatmeal in the form of a 
gruel to which sugar was added was given, largely because of its high proteid 
content. Beef-juice, scraped beef, and pure cod-liver oil were also given about 
this time. At the completion of the first year a portion of a soft egg was added to 
the diet. Zwieback and bread-crusts soaked in sugar-water were also used. 
These solid substances were given two or three times a day, after which the child 
was nursed. Pure cod-liver oil was given almost continuously during the second 
year. Butter-fat could be taken without inconvenience when she was one year 
of age. Following out the above lines of treatment, the child was weaned when 
thirteen months of age. She has since been fed with an entire absence of cow's 
milk from the diet. When six years of age her weight was 55 pounds, height 48 
inches. She was normal in every respect, but six ounces of milk given at one time 
would produce a coated tongue, foul breath, constipation, and excessive irritability 
which w^as entirely foreign to her nature. At the twelfth year the intolerance for 
milk w^as entirely overcome. 

The young mother of a vigorous, eight-months'-old breast-fed girl determined to 
wean the baby. The family physician prescribed a suitable formula. The child 
refused to take the milk mixture. A small quantity was taken and immediately 
vomited. After further unsuccessful attempts at feeding two ounces were forced. 
This w^as at 10 a. m. The child did not vomit, but passed into a condition approach- 
ing collapse. When I saw the child a few hours later she presented the appearance 
of a case of severe intestinal intoxication. She was very apathetic, but could be 
aroused with difficult^^ The pulse was small, very soft, and thready. The res- 
piration was superficial, but not rapid. The eyes were sunken, the skin blanched. 
In spite of active stimulation and external heat the child grew gradually weaker, 
making but temporary response to stimulation, and died seventeen hours after 
the milk had been given. The case was one of anaphylactic shock from the milk 
proteid. I have seen many cases of allergy to foods, but this case is my only 
fatality. 

A boy whom I treated for colitis gave a historj^ of allergy to milk. The 
placing of a few drops on his tongue would be followed immediately by intense 
general urticaria. 

A vigorous, nine-months'-old breast baby was given a feeding of cow's milk and 
vomited it at once. In a few days another feeding was attempted. The child'took 
only a swallow or two of the food, but at once developed general urticaria. The 
ears suddenly became several times their normal size, and the eyelids swelled and 



100 THE PRACTICE OF PEDIATRICS 

closed the eyes. The respiration became greatly impeded through edema of the 
glottis to the extent that the mother feared the child would suffocate. I saw him 
six hours later; the voice was still hoarse and croupy. Three weeks later five drops 
of milk were placed on this baby's tongue. In three minutes he vomited and 
became decidedly pale; in a few minutes more he vomited again. This was 
followed by hiccup which lasted until he left the office one-half hour later. The 
child is still under observation, and so sensitive is he to milk proteid that a vac- 
cination with milk will produce at the site of the scarification a large urticarial 
wheal. The wheal is also produced by egg-white. Many cases show intolerance 
to milk, but in lesser degree. 

THE AMMONIACAL DIAPER 

Probably every physician has been told by the mother or nurse that 
the baby's diaper smells of ammonia. South worth found in a study of 
several cases that the condition was readily corrected by eliminating or 
reducing the fat in the milk or by giving alkalies, such as magnesia or 
citrate of potash. 

This author, quoting Czerny and Keller accounts for the excessive 
ammonia excretion as "depending upon the chemical property of 
ammonia to combine with acids as an alkaline base. While under nor- 
mal conditions all but a little of the ammonia becomes urea and is 
excreted as such, if under abnormal conditions there is present in the 
body an excess of unoxidized acids for whose neutralization the avail- 
able supply of fixed alkalies does not suffice, the ammonia can then take 
the place of fixed alkalies and form with the acids ammonia salts, which 
will be excreted in the urine.'' 

Treatment. — The management of these cases as suggested above 
rests in reducing the fat to the child's capacity, or in the use of alkalies. 
In my own cases the reduction of the fat content in the food has been 
all that was required. A reduction of 2 per cent, of fat in the food 
mixture will usually suffice to correct the condition. 

TARDY MALNUTRITION AND MALNUTRITION IN OLDER 
CHILDREN 

Malnutrition, with tuberculosis and syphilis, is not a part of our 
subject. In the sections on Malnutrition in Infants and Children it 
may be thought that there is repetition of what is said under the title 
of the Delicate Child. While the management necessarily is along 
the same lines, two distinct types of children are represented. The 
marasmic and malnutrition infant or young child may be but tem- 
porarily delicate. When the child with simple malnutrition recovers, 
he may develop into as normal a specimen of robust childhood as 
could be desired. The delicate child as I have endeavored to describe 
him is inherently delicate, and our efforts are toward improving his 
condition, with the hope, perhaps, but with no great assurance, that 
he will some time become a robust adult. 

Tardy malnutrition is usually seen in children of the school-age, 
although it may appear any time after the third year. They are de- 
ficient in weight, in resistance to disease, and in capacity for work; 
they are pale, thin, tired children. 



TARDY MALNUTRITION 101 

Etiology. — Cases of tardy malnutrition as well as those of maras- 
mus and infantile malnutrition are seen in all the walks of life, among 
the wealthy, the so-called middle class, and among the poor. Strange 
as it may seem, these cases, regardless of the station of life, have two 
causes, common to all, waste of energy and defective feeding. The 
scion of wealth who is overfed or badly fed — given food which is un- 
suitable, and allowed the promiscuous use of sweets — may develop 
malnutrition just as effectively as the child of the tenement who sub- 
sists on fried meats, grocery milk, boxed breakfast foods, and poorly 
cooked vegetables. 

The most important factors in these cases are overwork — exces- 
sive energy output, in school, at work, or at play — ^and inadequate rest. 
The child is active from early morning until bedtime at 7 or 8 o'clock. 
This entails waste of vitality and the organism suffers. Every child 
until the seventh year should have an after-dinner rest, sleep if possible, 
for one to one and one-half hours. There should be twelve hours of 
uninterrupted sleep at night. 

In all cases errors in the daily life of the patient will be most 
apparent. 

There is a painful lack of knowledge among all classes as regards 
the nourishment required by a growing child. He is fed to satisfy 
his appetite, and when this is accomplished, the parents believe that 
their duty is done. How far they fall short of proper feeding is demon- 
strated daily in out-patient clinics and in private work. Poverty is 
an occasional cause of bad feeding in New York City. 

Treatment. — I have repeatedly seen children from five to ten years 
of age, with marked malnutrition, gain from 3 to 5 pounds the first 
month under treatment which consisted simply in inaugurating the 
midday rest and in giving food that they had a right to demand, 
properly prepared at definite intervals. The school-child suffering 
from malnutrition should be removed from school temporarily, and 
as much outdoor life as possible should be enjoyed by him, regardless 
of his station in life. Everything of a strenuous nature should be 
avoided. He should be put to bed early and encouraged to sleep late. 
A midday rest for one who shows marked emaciation and diminished 
resistance is advised. 

Illustrative Cases. — The following is quite a usual history of an advanced case 
of malnutrition in a girl, seven years of age, and the treatment is that which we 
usually employ: The mother brought the girl to the out-patient service at the New 
York Polyclinic because the child was pale, did not grow, and was always tired — 
too tired to go to school, of which she was very fond; too tired to play with other 
children, as had previously been her custom. Her weight was 41 pounds. There 
was loss of appetite, no food being taken except on compulsion. There was no 
evidence of congenital syphilis or tuberculosis. There was a secondary anemia. 
The child slept in a badly ventilated room; she drank tea and coffee. Cake, 
pastry, and sweets were her regular diet, and because she did not eat at meal- 
times she was allowed to eat between meals whenever and whatever she pleased. 
The following mode of life and diet was prescribed: She was to sleep in the front 
room, known as a sitting-room or parlor, with a window open at least six inches. 
She was given three meals a day with nothing whatever between meals. The diet 
consisted of red meat once a day, two or three soft-boiled eggs daily, one quart of 
good milk daily if it agreed (and it did agree). She was to have only natural 



102 THE PRACTICE OF PEDIATRICS 

cereals, such as oatmeal, cracked wheat, and cornmeal — each of which was to be 
cooked three hours the day before it was to be given. Baked or boiled potatoes 
and one green vegetable were to form a part of the dinner at midday. Stewed and 
raw fruits and plain puddings with home-made bread and plenty of butter com- 
pleted the dietary. She was put to bed at 7 o'clock and arose at 7 the following 
morning. An after-dinner rest in a darkened room for an hour was insisted upon. 
Before retiring she was given a brine bath (p. 780), followed by a brisk drying with 
a rough towel, after which her entire body was rubbed for ten minutes with olive 
oil. In one month a radical change had taken place. She had gained 4 pounds in 
weight. Her color was good. She complained no more of languor or fatigue. 
She was eager for school. The improvement continued, and in ten weeks she made 
a perfect recovery. In not every case will results be so prompt and satisfactory. 
In some, a longer time will be required before pronounced results are to be seen. 
Every child suffering from malnutrition of this type cannot help being benefited 
more or less by such a regime. 

A most pronounced case of this type was in a boy, eight years of age, who pre- 
sented a most dilapidated picture. He was tall for his age, very thin, pale, habitu- 
ally tired, and had a well-developed habit-spasm. He was restless, active, and 
played hard when he was not too tired to play. His weight was 593^^ pounds. 

The living regime prescribed was as follows: He breakfasted at 7.30 a. m. He 
was to remain in bed until 10 o'clock in the morning, then up and about at play as 
he wished. Dinner at 12.30 was followed by a rest of one and one-half hours. 
Play was permitted without particular restraint until supper at 6.30. Bedtime 
was 7.30 p. M. He improved rapidly and in one month was permitted to arise 
with the family. From October 12th to May 27th he gained in weight 19}^ pounds. 

I have treated a great many of these cases of malnutrition in older 
children in the same manner, by limiting the energy output, and right 
feeding. A gain of from 2 to 6 pounds a month for the first month or 
two is the usual result of the treatment. At the same time there is a 
radical change in the child's mental attitude and general appearance. 

Tonics. — The tincture of nux vomica, 4 drops in water before meals, 
is sometimes given to children whose appetite is defective. One grain 
of the citrate of iron and quinin in 1 dram of equal parts of sherry wine 
and water may be substituted. If there is secondary anemia and a 
defective nerve resistance, the following prescription is given, inter- 
rupted by five days free from medication. 

For a child five to ten years of age: 

I^ Liq. potassii arsenitis Tijjlxiv 

Liq. ferri albuminati Sjv 

Syr. hypophosphitum (calcis et sodae) S iij 

Aquae . . . .q. s. ad Bvj 

M. ft. Sig. — One teaspoonful after meals in water. 

During the five days without the medication cod-liver oil may be 
given. 

Constipation. — If constipation is present, olive oil may be given 
internally, 2 or 3 drams after meals. If the oil is not well taken, or if it 
disagrees in any way, its use should be discontinued. Liquid albolene 
(aromatic), in J^ to 1 ounce dosage at bedtime, answers well in many. 
The dosage may be gradually reduced and later discontinued. 

Feeding After the First Year 
general properties of foods 

Substances used as foods, regardless of the animal which they may 
nourish, possess the common property of being composed of fat, pro- 



GENEKAL PROPERTIES OF FOODS 103 

teids, carbohydrates, mineral substances, and water, in varying propor- 
tions. The purposes that these serve in the animal economy are essen- 
tially the same in all forms of animal life. In order to determine the 
food-value of any substance, a chemical analysis which shows the 
quantities of these nutritional elements is required. It will be found 
that foods varying widely in appearance and physical properties are 
still similar in that they are composed of the same food elements, al- 
though in different proportions. 

Foods used to sustain animal life in any form must contain the 
ingredients needed, and these must be present in a form suited to the 
particular kind of animal to be fed, whether it is man or one of the 
lower animals. 

The Ingredients of Foods. — In the individual foods the nutritional 
elements exist in widely differing forms. Fat may be supplied in meat, 
cream or milk, butter, oleomargarin or butterine, lard, olive oil, cod- 
liver oil, linseed oil, cottonseed oil, etc. Carbohydrates may be 
furnished in the form of cane-sugar, milk-sugar, maltose, and dextrose 
— soluble products derived from starch, corn-starch, wheat or other 
flour, oatmeal, rice, hominy, bread, potatoes, etc. Proteids are secured 
in the form of lean beef, lamb, or pork, chicken, fish, the gluten of such 
cereals as wheat and oats, and also in large quantities from peas, beans, 
lentils, and other legumes, from the curd of milk, and from eggs. The 
mineral substances of food are found combined with the other ingredi- 
ents in the form of lime, phosphates, magnesium, etc. 

The Function of the Food Elements. — The proteids of the food are 
used to form the bodily structures and to replace tissue consumed by 
the vital processes and excreted as urea. The vital processes, such as 
the circulation of the blood, respiration, and contractions of the 
muscles, call for energy, and this, together with bodily heat, must be 
supplied by the fats and carbohydrates. The mineral substances are 
used in the formation of bone and teeth, while the water serves to 
dissolve the food elements after they have been digested and to carry 
off waste products. 

The Advantage of a Knowledge of the Composition of Foods. — 
Inasmuch as each food element has a special function to perform, and 
since growth is impossible without a sufficient supply of these nutri- 
tional elements, particularly the proteid, it is essential to know within 
reasonable limits the composition of a food, because if the elements are 
not present in proper proportions, disappointing results may be obtained 
from their use, which will appear inexplicable, but which will readily 
be accounted for if we know what element of the food is at fault. For 
these reasons it is coming to be the practice, in infant-feeding especially, 
to speak of the percentage composition of the milk-foods as, for ex- 
ample, a food containing 4 per cent, fat, 7 per cent, carbohydrates, 2 
per cent, proteids, and 0.35 per cent, mineral substances. Knowing 
from wide experience the percentages of these ingredients generally 
needed in a food if it is properly to nourish a child, the physician can 
determine in an instant whether an infant is having a food of suitable 



104 THE PRACTICE OF PEDIATRICS 

nutritive value, by comparing its known composition with that estab- 
lished, by experiment, as requisite. 

The Selection of Food. — In a review of analyses of foods many 
substances will be noticed which, according to their chemical compo- 
sition, have the same food-value, but which common sense tells us are 
not interchangeable. For instance, no one would attempt to feed to a 
human being cracked oats unless thoroughly cooked, but he would give 
them raw to the lower animals. They will nourish a man or the animal 
equally well, but for man they must be prepared, while the horse, for 
example, can utilize them in their original state. This illustrates the 
importance of adapting food to the consumer. Often the question in 
feeding is not so much. Is the food nutritious? as. Can the patient 
assimilate it? Oftentimes success in infant-feeding lies in the physi- 
cian's ability to discover a form of fat, carbohydrate, and proteid which 
the infant can assimilate. In the following pages feeding measures for 
temporary use will be found which may not conform to what some may 
consider strictly scientific principles; yet they often give brilliant re- 
sults. Looking a little below the surface, it will be found that the 
measures suggested are not unscientific, and that the results are due to 
applying the fixed principles of nutrition in perhaps novel or unusual 
ways. It is usually best to follow the most direct route to any place, 
but when this is badly blocked it is better to go another way, if there is 
one, rather than not to arrive at one's destination. 

General Properties of Milks. — When most young animals are 
born, their digestive organs are in a more or less embryonic condition, 
and it is several months before they entirely outgrow this state. Dur- 
ing this period the nourishment is supplied by the mother through her 
mammary glands, first as colostrum and later as milk. When these 
secretions are analyzed they are found to consist of fat, carbohydrates, 
proteids, mineral substances, and water, and in this respect they do not 
differ from other foods. But the elements exist in the secretion in 
peculiar forms, and the natural inference is that in some way they must 
be particularly suited to animals whose digestive organs are still 
undeveloped. 

The digestive secretions of the stomachs of all known animals con- 
tain pepsin and hydrochloric acid. In the very young these secretions 
are feeble, but as development proceeds they are much more abundant. 
To understand milk as a food one must know the effect upon it of pepsin 
and acid. When pepsin is added to tepid cow's milk it causes the milk 
to gelatinize, with the formation of curd or junket. If the milk is 
slightly acidified or soured, the curd formed is dense and solid and more 
difficult of digestion. When the milk of the cow or the ass or human 
milk is treated with pepsin and acid in exactly the same way, curds 
totally different are formed, and as the human digestive organs are differ- 
ent from those of the cow or the ass, it is believed that these differences 
in the digestive properties of milks are for the purposes of making the 
milks suitable for the different kinds of digestive tracts. Milks may be 
regarded as special forms of food which require greater digestive effort 



DIET FROM THE FIRST TO THE SIXTH YEAR 105 

as the digestive secretions of the stomach become stronger, and thus 
soHd food is furnished to the developing stomach. It is that portion of 
the proteid of the milk called ''casein" that is changed into a solid by 
the pepsin of the stomach. The term casein, however, has been loosely 
applied to all the proteids of all milks. The caseins of all milks are not 
alike in their digestive properties. Therefore, the mistake of so con- 
sidering them should be guarded against. A consideration of such a 
modification and adaptation of cow's milk as will make it acceptable to 
the infant's digestive possibihties will be found in the chapter dealing 
with Substitute Feeding. 

DIET FROM THE FIRST TO THE SIXTH YEAR 

At the completion of the twelfth month the average well-regulated 
baby should be weaned and given other nourishment. If bottle-fed, 
he should receive more than the milk and cereals, with which most 
children are fed. The food suitable for the second year of life and the 
method of its preparation and administration are subjects concerning 
which the masses are most profoundly ignorant. A few children at this 
period of life are underfed, but the great majority are overfed and care- 
lessly given, at improper intervals, unsuitable food, indifferently pre- 
pared. Summer diarrhea finds its greatest number of victims among 
those children over twelve months of age who have been carelessly fed. 

The Second Summer. — The dreaded ''second summer" robs many 
homes because of ignorant or careless parents. The second summer, 
approached properly, is hardly more dangerous than any other summer 
during the early years of a child's life. It is almost a universal custom, 
when the child is weaned or given something other than a milk diet, to 
allow him "tastes" from the table. Very often these tastes comprise 
the entire dietary of the adult. Milk is oftentimes the only suitable 
article of diet that is given. Eventually, not only is the other food 
selected unsuitable, but it is given irregularly, and supplemented by 
crackers kept on hand for use between meals. During the hot months 
the gastro-intestinal tract is less able to bear such abuse and the child 
becomes ill. 

Feeding After the First Year. — Usually when the twelfth month 
is completed I give the mother a diet schedule, with instructions to 
begin gradually with the articles allowed, in order to test the child's 
ability to digest them. Every new article of food should be carefully 
prepared and given at first in very small quantities. All meals are to 
be given regularly, with nothing between meals. With many chil- 
dren this expansion of the diet-list is attended with considerable diffi- 
culty. They are thoroughly satisfied with milk, and refuse all other 
forms of nourishment. In such cases time and patience are necessary 
at the feeding-time. The more solid articles of diet should be given 
first and the milk kept in the background. 

Among the underfed seen at this period of life are those who were 
nursed too long or those who were kept too long upon an exclusive milk 



106 THE PRACTICE OF PEDIATRICS 

diet. A great majority of the cases of malnutrition of the second year 
are seen in the exclusively milk fed. These children are pale, soft, 
flabby, and badly nourished. 

The following is a diet schedule which I have employed for several 
years. Each mother is instructed to select, from the foods allowed, a 
suitable meal : 

From the twelfth to the fifteenth month; five meals daily: 

7 A. M.: Oatmeal, barley or wheat jelly, one to two tablespoonfuls 
in 8 ounces of milk. (The jelly is made by cooking the cereal for four 
hours the day before it is wanted and straining through a colander.) 
Stale bread and butter or zwieback and butter. 

9 A. M. : The juice of one orange. 

11 A. M.: Scraped rare beef, one to three teaspoonfuls, mixed with 
an equal quantity of bread and moistened with beef -juice. Or a soft- 
boiled egg mixed with stale bread-crumbs; a piece of zwieback and a 
half-pint of milk. 

(Scraped beef is best obtained from round steak, cut thick and 
broiled over a brisk fire sufficiently to sear the outside. The steak is 
then split with a sharp knife and the pulp scraped from the fiber.) 

3 p. M.: Beef, chicken, or mutton broth, with rice or stale bread 
broken into the broth. Stale bread and butter or zwieback and butter, 
apple-sauce and prune pulp; corn-starch pudding, junket. 

6 p. M.: Two tablespoonfuls of cereal jelly in 8 ounces of milk; a 
piece of zwieback. Stale bread and butter or Huntley and Palmer 
breakfast biscuit. 

10 p. M. : A tablespoonful of cereal jelly in 8 ounces of milk. 

From the fifteenth to the eighteenth month; four meals daily: 

7 A. M. : Oatmeal, hominy, cornmeal, each cooked four hours the day 
before they are used. When the cooking is completed, the cereal 
should be of the consistence of a thin paste. This is strained through 
a colander, which upon cooling will form a mass of jelly-like consistence. 
Of this give two. or three tablespoonfuls, served with milk and sugar, or 
butter and sugar, or butter and r^alt. Eight to ten ounces of milk as a 
drink. Zwieback or toast. 

9 A. M. : The juice of one orange. 

11 A. M.: A soft-boiled egg mixed with stale bread-crumbs, or one 
tablespoonful of scraped beef (p. 70), mixed with stale bread-crumbs 
and moistened with beef-juice, or a tablespoonful of minced white meat 
of chicken. A drink of milk. Zwieback or bran biscuit, or stale bread 
and butter. 

3 p. M.: Mutton, chicken, or beef broth, with rice or with stale 
bread broken in the broth. Custard, corn-starch, plain rice pudding, 
junket, stewed prunes, baked apple, or apple-sauce. 

6 p. M.: Farina, cream of wheat, wheatena (cooked two hours). 
Give from one to three tablespoonfuls, served with milk and sugar, or 
butter and sugar, or salt and butter. Drink of milk. Zwieback or 
stale bread and butter. 



DIET FROM THE FIRST TO THE SIXTH YEAR 107 

From the eighteenth to the twenty-fourth month; Jour meals daily: 

7 A. M.: Cornmeal, oatmeal, hominy (prepared as in the above 
schedule). Serve with butter and sugar, or milk and sugar, or butter 
and salt. A soft-boiled egg every two or three days. Hashed chicken 
on toast occasionally. A drink of milk. Bran biscuit and butter or 
stale bread and butter. 

9 A. M.: The juice of one orange. 

11 A. M.: Rare beef, minced or scraped; the heart of a lamb chop, 
finely cut; minced chicken. Spinach, asparagus tips, squash, strained 
stewed tomatoes, stewed carrots, mashed cauliflower. Baked apple or 
apple-sauce. Stale bread and butter. 

After the twenty-first month baked potatoes and well-cooked 
string-beans may be given. 

3 p. M.: Chicken, beef, or mutton broth, with rice or with stale 
bread broken into the broth. Custard, corn-starch, or plain rice pud- 
ding, junket, stewed prunes. Bran biscuit and butter or stale bread 
and butter. 

6 p. M.: Farina, cream of wheat, wheatena (each cooked two hours). 
Give from one to three tablespoonfuls, served with milk and sugar, 
or butter and sugar, or butter and salt. Drink of milk. Zwieback or 
stale bread and butter. 

After the eighteenth month a large number of children will have a 
better appetite and thrive more satisfactorily on three full meals a day. 
The breakfast is advised at 7.30 a. m. and the dinner at 12 o'clock. 
At 3 p. M. or 3.30 p. m. a cup of broth and a cracker or toast and a drink 
of milk may be given. 
From the second to the third year; three meals daily: 

Breakfast: 7 to 8 o'clock. Oatmeal, cornmeal, hominy, cracked 
wheat (each cooked four hours the day before they are used), served 
with milk and sugar or butter and sugar. A soft-boiled egg, or 
minced chicken. Stale bread and butter. Bran biscuit and butter. 
A drink of milk. 

At 10 o'clock the juice of one orange may be given. 

Dinner: 12 o'clock. Strained soups and broths, rare beefsteak, 
rare roast beef, poultry, fish. Baked potato, peas, string-beans, squash, 
mashed cauliflower, mashed peas, strained stewed tomatoes, stewed 
carrots, spinach, asparagus tips. Bread and butter. For dessert: 
plain rice pudding, plain bread pudding, stewed prunes, baked or 
stewed apple, junket, custard, corn-starch, or gelatine pudding. 

Supper: 5.30 to 6 o'clock. Farina, cream of wheat, wheatena 
(each cooked two hours). Give from one to three tablespoonfuls 
served with milk and sugar, or butter and sugar, or butter and salt. 
Drink of milk. Zwieback or stale bread and butter. Twice a week 
mustard, corn-starch, or junket may be given, or a tablespoonful of 
plain vanilla ice-cream. 

As a rule, three meals answer best at this period. With three 
meals a child has a better appetite and much better digestion, and 
consequently thrives far better than one whose stomach is kept con- 



108 THE PRACTICE OF PEDIATRICS 

stantly at work. Some children, however, will require a luncheon 
at 3 or 3.30 p. M., and will not do well without it. This is apt to be the 
case with delicate children, particularly those under two and one-half 
years of age. If food is necessary at this hour, a glass of milk and a 
Graham biscuit or a cup of broth and zwieback will answer every pur- 
pose. Instead of the afternoon meal, the child may relish a scraped 
raw apple or a pear. Fruit at this time is particularly to be advised 
if there is constipation. Children recovering from serious illness 
will require more frequent feeding. 
From the third to the sixth year: 

Breakfast: Cracked wheat, cornmeal, hominy, oatmeal (each 
cooked four hours the day before they are used). These may be 
served with milk and sugar, or butter and sugar, or butter and salt. 
A soft-boiled egg, omelet, scrambled egg. Bread and butter, bran 
biscuit and butter. A glass of milk. 

Dinner: Plain soups, rare roast beef, beefsteak, poultry, fish, 
creamed or baked potatoes. Peas, string-beans, strained stewed toma- 
toes, stewed carrots, squash, boiled onions, mashed cauliflower, 
spinach, asparagus tips, bread and butter. For dessert: Rice pud- 
ding, plain bread pudding, custard, tapioca pudding, gelatine pudding, 
stewed prunes, stewed apples, baked apples, raw apples, pears, and 
cherries. 

Supper: Farina, cream of wheat, wheatena (each cooked two hours) . 
Give from two to three tablespoonfuls, served with milk and sugar, or 
butter and sugar, or butter and salt. Zwieback or stale bread and 
butter. Bread and milk. Milk-toast. Scrambled eggs twice a week. 
Custard or corn-starch each once a week; ice-cream once a week. 
Bread and butter. A glass of milk. 

When the child has eggs for breakfast, they should not be repeated 
in any form for supper. Red meat should be given but three times a 
week. When the child has a chop for breakfast, he should have 
poultry or fish for dinner. At this age of great activity and rapid 
growth the child will often demand food between dinner and supper. 
Carefully selected fruit, such as an apple, a pear, or a peach, may be 
given at this time, supplemented by a Graham cracker or two, or by 
stale bread and butter, if it is found that their use does not interfere 
with the evening meal. 

DIET AFTER THE SIXTH YEAR 

When the normal child has passed the sixth year the diet may be 
considerably expanded, approximating to that of the adult in variety; 
certain restrictions, however, are to be borne in mind. Fried foods 
should not be given; highly seasoned dishes, such as pie, rich puddings, 
gravies, and sauces, are to be avoided. Salads with plain dressing may 
now be given. Wine and beer, coffee, and tea should never be given 
to children as a beverage. A point to be kept in mind in feeding chil- 
dren of this age, as well as those who are younger, is the proper cooking 



DIET DURING ILLNESS 109 

of vegetables. Everything in the Hne of green vegetables should be 
cooked until it can readily be mashed with a fork. 

DIET DURING ILLNESS 

The digestive capacity of every child is diminished during illness, 
the extent depending largely upon the age of the child and the severity 
of the disease. The younger the child, the greater the incapacity. 
This is fairly constant with all the ailments of childhood, including, of 
course, those which directly affect the gastro-enteric tract. 

Reduction in Food Strength. — In a moderately severe bronchitis, 
with a degree or two of fever, the digestive capacity is slightly diminished 
and a 25 per cent, reduction in the strength of the food will answer. 
During the critical stage of a lobar pneumonia the digestive powers 
are held in abeyance and predigested foods and alcohol must sustain 
the patient. During an attack of measles, scarlet fever, broncho- 
pneumonia, or diphtheria in bottle-fed infants, at the height of the 
disease, it is my custom to reduce the strength of the food one-half by 
the addition of water, to make up for the quantity removed. For ail- 
ments of lesser severity, such as bronchitis, with a temperature of 100° 
to 101°F., or chicken-pox, or mild measles, I reduce the strength of the 
food from one-fourth to one-third. In the event of any mild ail- 
ment or injury which confines a child to his bed, the food strength 
should be cut down, for inactivity as well as disease lessens the digest- 
ive capacity. 

Among nurslings and the bottle-fed these precautions are particu- 
larly necessary. A child with fever is apt to be thirsty and to take 
more fluid than in health. This is frequently the case during summer 
diarrhea. In order to prevent taking too much food, I not only order 
that the milk be diluted for the bottle-fed, but I instruct the mothers 
of nurslings to give a drink of water immediately before each nursing 
and between nursings, and then to allow the child to nurse only one- 
half or two-thirds the usual time. For the bottle-fed, one-half to one- 
third of the contents of each bottle is removed and the quantity re- 
placed by boiled water, so that the amount of fluid given remains the 
same. 

If a child is a ''runabout," over two years of age, he is given broths 
and thin gruel — one-half milk and one-half gruel. By carefully watching 
the stools, thus fitting the food to the child's capacity, we will avoid 
grave intestinal complications which, during the summer, often prove 
to be more serious than the original ailment. In the acute gastro-enteric 
troubles and in typhoid fever, all milk must be discontinued. 

The dietetic management of the acute intestinal diseases and 
typhoid fever is referred to in detail under the respective headings. 

The Art of Feeding in Illness. — Not only is food oftentimes taken 
in insufficient quantity in illness, but in many cases it is absolutely 
refused. In other cases, during coma and asthenic states, swallowing 
IS impossible. In delirium and in conditions of collapse nourishment 



110 THE PRACTICE OF PEDIATRICS 

must be given, and when this is impossible by the natural method, we 
have, as temporary substitutes, gavage, oil inunctions, and rectal feed- 
ing — all referred to elsewhere. 

Forcing the child to take nourishment by the mouth is rarely neces- 
sary. Coaxing and bribing ordinarily succeed far better. For a child 
from three to five years of age a bright new penny possesses much per- 
suasive power. The child will usually take food better from one to 
whom he is accustomed, like the mother or nursery maid. The 
trained nurse should understand that while she is unacquainted with 
the patient, the simpler requirements of the child are to be looked 
after by others to whom the patient is accustomed. 

The nourishment should be as palatable as possible and served 
in bowls, cups, or plates that are attractive to the patient, because of 
color, pictures, or peculiarities of shape. Junket, flavored with vanilla, 
served cold, is a favorite food for sick children of the ''runabout'^ age. 
Frozen custard and home-made ice-cream, made with one-third cream 
and two-thirds milk, will usually be well taken. Toast, dry bread, and 
crackers made in peculiar shapes are attractive to the child. In not a 
few cases I have succeeded in feeding satisfactorily children two or 
three years old, when several other schemes had failed, by allowing 
the temporary return to the bottle, from which they had been weaned 
for a year or so. 

In these difficult feeding cases the child's peculiarities and wishes 
must be studied. Children in illness require water. Oftentimes they 
take it in insufficient quantities. Those who refuse plain water will 
often take ginger ale, sarsaparilla, or vichy. In the event of these 
drinks being well taken, they may be given freely. In the acute in- 
fectious diseases, which include pneumonia, free water-drinking is a. 
therapeutic measure of no mean value. 

COMMON ERRORS IN FEEDING 

In the care of the bottle-fed the most frequent error is overfeeding^ 
or the use of a stronger mixture than the child is able to digest. Par- 
ticularly is this apt to be the case at the commencement of bottle-feed- 
ing. The amount is usually too large and the intervals between the 
feedings are almost invariably too short. Children of the same age 
cannot all he fed alike. Artificially fed babies of equal health and 
vigor, but of considerably varied size and weight, will require food 
of approximately the same strength, and the same intervals between 
feedings; but the larger the child, the greater the quantity of food- 
required. Thus, the quantity given at one feeding for a child weigh- 
ing 13 pounds at the sixth month will not be sufficient for a child of the 
same age weighing 16 pounds. 

The quantity of food for each feeding for an average baby weighing 
15 pounds at six months is about 6 ounces, and this quantity should be 
diminished 3^^ ounce for every pound under this weight until the total 
quantity is reduced to 4 ounces; and for every pound over 15, }/2 
ounce should be added to each feeding until the total is increased to 9' 



SCURVY (scorbutus) 111 

ounces. The number of feedings in twenty-four hours should be the 
same for all young children of the same age. In the table of food for- 
mulas given on p. 70 only the average child of average weight is con- 
sidered. 

AGE OF CHILD, SIX MONTHS 

Weight of Child Quantity for Each Feedino 

11 pounds 4 ounces 

12 pounds 43>^ ounces 

13 pounds 5 ounces 

14 pounds 5^^ ounces 

15 pounds 6 ounces 

16 pounds Q}4 ounces 

17 pounds 7 ounces 

18 pounds 73^ ounces 

19 pounds 8 ounces 

20 pounds 8K ounces 

21 pounds 9 ounces 

Keeping the child on an exclusive milk diet until the twelfth month 
or later is a not infrequent error. As a rule, starch in some form 
may be added to the food at the seventh month, and should always 
be added as early as the ninth month. The giving of food other 
than well-cooked cereals and milk before the twelfth month is a 
mistake made in many households, and a common error from the 
twelfth month to the third year is to allow the child 's diet to consist 
largely of milk and insufficiently cooked cereals. Crackers and 
milk, bread and milk, cake, and fancy crackers, often constitute 
the only articles of diet during this very important period of growth. 
The fact that a high proteid food is as necessary for proper develop- 
ment now as at bottle age, is overlooked. During early infancy 
milk is invaluable, but it is not sufficient for the demands of older 
childhood. Milk, eggs, meat, and cereals, such as oatmeal, rich in 
proteid, are absolutely necessary to normal growth. 

Irregularity in feeding is another frequent error. The child should 
have his meals '^on the minute," at the same time every day. The 
lack of observance of this rule will surely result in loss of appetite and 
indigestion. Indiscriminate eating between meals of bread and butter, 
pastry, or confectionery, if persistently practised, will surely be followed 
by indigestion and malnutrition. 

Forcing or coaxing a child to eat is a practice always to be 
avoided. If suitable food is given at definite well-ordered intervals, 
a normal child will be hungry at those intervals. If he does not eat, 
something is wrong, and it is our duty to discover the cause of his 
loss of appetite. 

SCURVY (SCORBUTUS) 

Scurvy in infants was first described by Glisson in 1651. It was 
not well recognized, however, until Moller described it again in 1859, 
viewing the disease as an acute type of rachitis. Ingelev, of Sweden, 
recognized a case of apparent infantile scorbutus in 1873, and in the 
period 1879-82 Cheadle reported several cases. In 1883 Sir Thomas 



112 THE PRACTICE OF PEDIATRICS 

Barlow was able to give a clear demonstration of the clinical features 
and pathology of this disease, and thenceforth reports of its occurrence 
were frequent. Infantile scurvy, or Moller-Barlow's disease, is a very 
definite affection, and, although the term '^ scurvy-rickets" still persists, 
this serves only to emphasize the frequent coexistence in a patient of 
the two essentially distinct conditions. 

Pathology. — ^The two leading features in the morbid anatomy 
of scurvy are multiple hemorrhages and rarefaction of bone. Whether 
the atrophy in the bone is, or is not, a result of the intra-osseous ex- 
travasations, seems uncertain. It is, however, believed that the rare- 
faction may occur primarily, independent of the hemorrhagic lesions. 
Although in some instances hematuria is the only prominent symptom, 
bleeding is usually not confined to any particular site, but may occur 
under the periosteum, in the bone-marrow, under the skin, under the 
membrane lining the serous cavities, or from the mucous surfaces. In 
the bones, the most severe lesions are found in the neighborhood of the 
epiphyses. The lymphoid marrow cells and the osteoblasts are dimin- 
ished in number, and there is increased porosity of the cancellous tissue. 
Fractures of the ends of the long bones are exceedingly common. In 
several cases I have seen separation of the epiphyses. In one case 
there were four so-called fractures — two at the shoulder-joint in each 
humerus, and two at the hips in each femur. Beneath the periosteum 
are extensive extravasations of blood, which frequently become organ- 
ized into firm layers of clot. In rare instances hemorrhages occur 
within the joints. 

In scurvy there are probably alterations in the capillary walls which 
permit the diapedesis of the red cells. Wright has recently shown that 
in this disease the alkalinity of the blood may be reduced to a point as 
low as ^%oo of the normal, and he regards scurvy as a form of acid 
intoxication. 

Autopsy upon a child that died from scurvy revealed extensive 
separation of the periosteum from all the long bones, from which mas- 
sive clots of blood were removed. 

Age.^ — The age incidence is significant. In a large number of cases 
I have seen but one over eighteen months of age ; this was in a child four 
years old. Occasionally scurvy occurs in infants under six months of 
age, but this is unusual. My youngest case was in a nursing baby 
three weeks old. In this infant there was a separation of the epiphyses 
at both wrists. 

Etiology. — The immediate toxic agent causing the hemorrhagic 
condition has not been discovered. It seems proved that there is some 
constitutional error, usually due to nutritional defects, which prepares 
the individual for whatever form of toxemia may be operative. 

In most instances the nutritional defect may be ascribed to the use 
of cooked foods. The well-known collective investigation of the Ameri- 
can Pediatric Society established the influence of foods that had been 
subjected to the influence of heat. Thus, 10 patients were entirely 
breast-fed, 4 were getting raw cow's milk, 116 were on pasteurized, 



SCURVY (scorbutus) 113 

sterilized, or condensed milk feeding, 214 were on proprietary foods. 
So pronounced a factor is cooked food in the production of scurvy that 
in all cases so fed I invariably give orange-juice, 2 or 3 teaspoonfuls 
daily. 

The heating of milk invariably removes something from it which is 
necessary for the prevention of scurvy; nevertheless, such cooking does 
not interfere with its nutritional properties. This I have demonstrated 
in hundreds of cases. 

Symptoms. — Malnutrition is not necessary for the development of 
scurvy, neither is previous illness a factor of much consequence. 

The first sign noticed is that of evident pain upon manipulation of 
different portions of the body, most frequently one of the legs. The 
complaint is that the child cries when the napkin is changed, or when 
he is being bathed or dressed. Further, the child, instead of freely. 
moving his arms and legs, allows one or more of his limbs to rest, while 
the others may be moved freely. 

In advanced cases all the limbs ma}^ be involved, and the child 
makes no attempt at even changing the position of a limb, and cries 
vigorously when such a change is made. The position taken by the 
child is that of outward rotation of the limb or limbs affected. 

In advanced cases the involved joint or joints will be swollen. The 
swelling may involve the entire limb. In a case occurring in my service 
at the Babies' Hospital the leg, from above the knee downward, was 
twice the size of the unaffected leg. 

Upon manipulation the parts are excruciatingly tender. I have re- 
peatedly had mothers complain that the child who previously had en- 
joyed attention in the way of handling and holding, preferred to lie 
quietly in his crib and apparently feared to be touched. 

While the long bones are usually involved, the other bony parts may 
be affected. In two children the ribs, spine, and scapula were affected. 
The extremities were normal. Both infants were about nine months of 
age. They cried vigorously when they were lifted by placing the hands 
around the body under the arms. The diagnosis of scurvy was proved 
by the quick and complete response to orange-juice and the use of un- 
cooked food. 

A few ecchymotic areas may be found on the skin, but this is 
unusual. 

Too much emphasis is placed upon this symptom, which is not an 
early manifestation and may not appear for two or three or more 
weeks after the first manifestation of the local lesion in the limbs. If 
the condition is not recognized, submucous bleeding almost invariably 
appears, and is characteristic, providing the child has teeth in the upper 
jaw; the gums in the lower jaw are rarely involved. The gums are 
swollen, edematous, and bleed readily. Over teeth about to be erupted, 
blood blebs of a dark-bluish color may be seen. In the absence of 
teeth the gums are usually normal. In a very few cases I have seen a 
slight bluish discoloration. It is only in the very advanced cases that 
the lower gum and teeth will show involvement. 
8 



114 THE PRACTICE OF PEDIATRICS 

Hematuria to a slight degree is present in most cases. In a few- 
instances it has been severe, showing macroscopic blood. Blood in the 
stools is of very rare occurrence. 

Prognosis. — The prognosis is very favorable. All cases recover if 
a reasonably early diagnosis is made and proper treatment instituted. 
If there is simply an involvement of a joint, of short duration, the child 
may be well in two to five days. In cases in which extensive lesions 
have formed, two or three weeks or more may be required for complete 
recovery. The longest time under treatment in my cases was three 
months. The patient was a baby eighteen months of age. He was 
taken to Dr. V. P. Gibney, who recognized the condition at once and 
referred the child to me for treatment. The child had been treated for 
rheumatism for three months. All four extremities were swollen to 
twice or three times their natural size, and were swathed in bandages, 
each saturated with a different lotion or liniment. In this way each 
liniment was to be tested out and the one that served best was to be 
selected for all the limbs. The odors emanating from the child were 
those of a chemical establishment in active operation. 

All previous local applications employed and those in use having 
failed, the case, with complete paralysis of all the extremities, was con- 
sidered a suitable one for the orthopedist. In addition to the symp- 
toms described, the gums were bleeding freely. In this child, the most 
severe case I have seen, the progress toward improvement was very 
slow. There was much extravasated blood to be absorbed, and in- 
fractions — how many I was not able to determine — to be healed. 
Resolution was, however, eventually complete. 

Differential Diagnosis. — Scurvy in infants was formerly most fre- 
quently confused with rheumatism. The age for scurvy — under 
eighteen months — is not the age for rheumatism. Scurvy is a disease 
of early infancy, and rheumatism, a disease of childhood. In rheuma- 
tism fever is a usual symptom. In scurvy there is no fever. From 
poliomyelitis scurvy may be differentiated by the acute pain upon 
manipulation and the presence of the knee-jerk. Specific epiphysitis 
may be mistaken for scurvy if the upper extremity is involved. The 
absence of other signs of syphilis, and a negative Wassermann test, will 
render a differentiation possible. Further, in any case which is doubt- 
ful, the use of orange-juice will, in a few days, through relieving the 
symptoms of scurvy, determine the diagnosis. This is a perfectly 
innocent procedure upon any evidence of pain in any of the limbs. 

Supposed trauma, such as a sprain or a fall, is the interpretation 
often applied to the symptoms of scurvy. Trauma in infants is most 
unusual, but possible, and the treatment test, orange-juice, may be 
required to differentiate. 

Treatment. — Dietetic. — The first step in the treatment is to supply 
fresh milk for the child, diluted, if necessary, to meet the digestive 
capacity. I have seen cases in which the diagnosis was made early 
recover without the aid of any other measure upon a change from 
sterilized milk or infant foods to raw milk. Inasmuch as the disease 



RACHITIS (rickets) 115 

is a most painful one, every means possible should be employed toward 
furnishing early relief. If orange-juice is not well tolerated, beef -juice 
may be given, or the juice of any ripe fruit, suitably diluted. The 
orange- juice very exceptionally disagrees with the digestion. A 
scorbutic child who has never tasted orange- juice will take it greedily 
and beg for more. One teaspoonful may be given at two-hour intervals, 
1 ounce being given ordinarily in twenty-four hours. Unless the case 
is an advanced one, with extensive subperiosteal hemorrhages and sepa- 
ration of the epiphyses, relief will be noticed in twenty-four hours and 
an entire cessation of symptoms in from five to seven days. I have 
seen a few cases entirely relieved at the end of seventy-two hours of 
treatment. These patients were infants in whom the diagnosis was 
made very early, the only symptom being the evidence of pain during 
manipulation of the limbs in bathing or while changing the napkin. 

The management of more severe cases is the same as of those of 
milder type. Fresh food, with orange-juice or beef-juice, must be 
freely given. The patients should be handled very gently, and only 
when necessary, as the pain on manipulation of the involved parts is 
most excruciating. In cases of epiphyseal separation splints should be 
temporarily applied. 

RACHITIS (RICKETS) 

Rickets was described by Whistler in 1645, and again in 1650 by 
Glisson. The disease has been more wide-spread in countries with cool, 
temperate climates than in tropical or semitropical regions, where the 
inhabitants live for the most part out-of-doors. Similarly, this disease 
shows a slightly greater tendency to develop during the winter than in 
the summer. Attempts to define the exact etiology of the condition have 
uniformly failed. Most of the prevailing theories have been reviewed 
by Dr. R. G. Freeman,* who found the disease most frequent in insti- 
tution babies who were fed on breast-milk supplemented by artificial 
feedings of condensed milk. In his opinion, both unsuitable food and 
infection or toxemia from the alimentary tract may be influential 
causes. 

Siegert in 1903 expressed the view that rickets was often hereditary, 
supporting his belief by observations- of severe cases in the breast-fed 
children of rachitic parents. By other authorities, however, rickets of 
congenital origin is held to be improbable or in any event exceedingly 
rare. 

Rickets is a chronic disease of nutrition. Its chief manifestations 
are in the bones during the growing period. It is peculiar, however, 
in that a greater part of the structure which goes to make up the infant 
organism may be involved in the rachitic process, which is in effect a 
metabolic derangement of wide possibilities. 

Age. — Rickets may occur at any age after the first month. It 
usually makes its appearance between the third and the twelfth 
months. Few cases develop before the first month. 

* "The Etiology of Rachitis," R. G. Freeman, Archives of Pediatrics, April, 
1904. 



116 THE PRACTICE OF PEDIATRICS 

Etiology. — Italian and negro infants show a decided predisposition 
to rachitis. A negro or ItaUan baby between six and twelve months 
of age in New York City without some evidence of rachitis is a curiosity. 

Much has been written regarding the etiology of the disease in 
its relation to climatic and unhygienic surroundings. While such sur- 
roundings may contribute to the result, I have yet to be convinced 
that as etiologic factors they are very important. It is true that we 
often find rachitic children in unhygienic surroundings, but thousands 
of others who live under the same conditions do not have rachitis. 
A child fed on normal breast-milk will endure and thrive in an environ- 
ment that typifies '' unhygienic conditions" (a popular term with 
writers). 

In the treatment of several thousand rachitic children one fact 
has impressed me most strongly: A child suffering from rachitis is 
suffering from nutritional errors as a result of improper feeding or 
inability to assimilate a suitable food ; and I have yet to see a case which 
will not improve when suitable nourishment can be given and assimi- 
lated, regardless of the age of the patient, provided, of course, there 
is no other disease. In children under one year of age prolonged 
feeding of the proprietary foods or sweetened condensed milk is the 
most frequent cause of the disease. The next most frequent cause 
is the feeding of a too strong cow's-milk mixture, which produces 
indigestion and faulty assimilation. 

Rachitis in the Breast-fed. — Breast-fed babies among the Italians 
and negroes often have mild rachitis, and an examination of the 
breast-milk will invariably show a diminution of one or more of the 
nutritional elements — usually the proteid. 

A nursing woman in the New York Infant Asylum had such a 
free flow of milk that a foster-child was given her to nurse. The 
children failed to thrive; each made a gain of but two or three ounces 
weekly; both developed rachitis, one in a marked degree. Repeated 
examinations of the breast-milk showed it never to contain more than 
1.5 per cent, fat, 4 per cent, sugar, and 0.5 per cent, proteid. 

I have time and again seen rachitis in breast-fed infants in whom 
the milk was adequate in amount, but deficient in nutritional elements. 
These cases will most often be seen from the seventh to the tenth 
month. 

After the First Year. — After the first year fewer cases develop, but 
a late rachitis is by no means uncommon. In my own cases the de- 
velopment of the disease at one year and after, as in the very young, 
has been distinctly traceable to faulty feeding and faulty digestion. 

Prolonged Nursing. — Not a few cases during the second and third 
years are due to prolonged nursing. I have known just two mothers 
who could nurse their children, and substantially nourish them, by the 
breast, later than the twelfth month. Usually when the breast fur- 
nishes the only means of nourishment after the ninth month, a be- 
ginning rachitis will soon be noticed. The feeding after the first year 
of an exclusive diet of milk or of digestible starches is not infrequently 



RACHITIS (rickets) 117 

a cause of rachitis. Among the poorer classes children during the 
second and third years are almost always badly fed. The diet often 
consists of poor milk and poorly cooked starches. Children thus fed 
furnish no small proportion of our rachitic patients. 

Association with Other Diseases. — The development of rachitis 
bears no relation to other disorders, excepting in its influence upon 
the nutrition of the patient. 

Theories of Pathogenesis. — Deficiency of lime salts in the system, 
either as the result of poor food or faulty assimilation, has been long 
regarded as the cause of the disease, but investigation has proved that 
rachitic subjects do not present the supposed variations from the 
normal, either in alkalinity of the blood or in lime elimination. 

Experiments in depriving young animals of fat have failed to 
render them rachitic. Attempts at bacterial inoculation have like- 
wise afforded -no convincing results. 

Monti, of Vienna, was able to demonstrate a diminution in 
hydrochloric acid associated with an excess of lactic acid in the 
stomachs of affected infants, and he coupled with this discovery the 
observation that the disease was more prevalent among the breast- 
fed infants of Saxony, whose mothers received little salt in their food, 
than in communities where the individual intake of sodium chlorid 
was normal. 

Recently, Hirschfeld has demonstrated the existence of a vaso- 
constrictor substance in the serum of rachitic infants. To the presence 
of this substance he ascribes the frequent coexistence of simple rickets 
with tetany, eczema, and such catarrhal conditions of the mucous 
membranes as are indicative of a so-called exudative diathesis. 

In the state of confusion arising from so many diverse theories we 
may summarize the results of clinical evidence in only a few facts: 
Rickets is infrequent in the breast-fed, unless colored or Italian; rela- 
tively infrequent amid good hygienic surroundings; rare before the 
age of three or four months, and uniformly absent from infants who 
have been taking and assimilating a substantial, well-proportioned food. 

Pathology. — The most obvious changes are in the bones. Here 
there is indeed a marked deficiency of lime salts. The formation of 
bone is interfered with not only at the epiphyses, but also in the region 
subjacent to the enveloping periosteum. 

In the epiphyseal ends of the long bones there is an excessive pro- 
liferation of the cartilage cells, and an abnormal vascularization of 
the zones of proliferation and calcification, which intervene between 
epiphysis and diaphysis. The deposit of lime salts in the cartilaginous 
matrix is imperfect, and- the solid cartilage undergoes a variable 
amount of absorption. As a result of these changes the epiphyses 
are softened and enlarged and the bones are subjected to varying 
deformities. 

Associated with the defective development at the epiphysis there 
is likewise incomplete formation of bone beneath the periosteum. 
This membrane is thickened, and the subperiosteal layer of bone, 



118 THE PRACTICE OF PEDIATRICS 

which normally undergoes calcification, is vascularized, soft, and 
deficient in calcium salts. 

" The pathologic changes may be summed up in the statement that 
there is excessive absorption of the bone with impairment of the 
process of calcification."* When the disease subsides, the imperfect 
bone undergoes calcification and hardening, but retains the deformities 
previously acquired. The enlargement of the epiphysis characteristic 
of rickets is usually first apparent at the costochondral joints, which 
acquire the well-known beaded appearance suggestive of the title, 
"rachitic rosary. ^^ In the more advanced cases the thorax under- 
goes actual distortions, defined by the terms, " Harrison^ s grooves'^ 
and "pigeon-breast.'^ Curvatures of the spine and pelvic deformities 
which may be combined with lordosis are common. In severe cases 
the legs become curved, owing to the inability of the bones to sus- 
tain the weight of the body, and portions of the cranial vault may 
undergo a variable amount of absorption. Localized areas of thin- 
ness in the occipital and parietal bones are characteristic of the 
craniotahes of rickets. The affected skull is large and the centers of 
ossification of the frontal and parietal bones are marked by hyper- 
ostoses or bosses. In many instances the anterior fontanel, instead 
of becoming closed at the twentieth month, remains patent until the 
third or fourth year. The eruption of the teeth is uniformly delayed 
and irregular. 

Although rickets is fundamentally a disease of general nutrition, 
the lesions, apart from those occurring in the osseous system, are of 
relatively slight significance. The spleen is frequently enlarged; less 
often, the liver. The stomach and colon may be dilated. The muscles 
undergo wasting, slight degenerative changes, and a variable amount 
of fatty infiltration. The ligaments are relaxed. The blood shows 
the existence of a secondary anemia and a mononuclear leukocytosis. 
Most of these conditions may, however, be considered secondary to, 
rather than characteristic of, the disease. 

Symptoms. — In a vast majority of the cases there are no symp- 
toms depending upon the presence of the disease. There may be 
sweating of the head, restlessness, constipation; but these symptoms 
are also present in cases which show no rachitic change. There is 
usually malnutrition, and yet malnutrition may be present without 
rachitis. Rachitic children are unusually susceptible to catarrhal 
conditions of the respiratory tract and they have a weak resistance 
to infection of the intestines; yet, again, we find these conditions in 
children who do not have rachitis. In rachitic children there is pro- 
nounced lack of nerve balance, and this occurs in children who do not 
have rachitis. All these conditions are present in rickets, and as a 
symptom-complex they point to rachitis. Such symptoms, therefore, 
are not diagnostic without further corroboration. 

So far as the pathognomonic symptoms are concerned, which 
means the conclusive manifestations of a disease, there are none. 
* Adami and Nicholls: Principles of Pathology, vol. ii, p. 1009. 



RACHITIS (rickets) 119 

The signs proving rachitis comprise the physical appearance of 
the child, the findings upon physical examination, and the evidence 
demonstrated by postmortem examinations. 

Diagnosis. — In a well-marked case inspection shows a condition 
that is seen in no other disease. There is the large head, cuboid in 
shape, flat on the top, due somewhat to the exaggeration of the frontal 
and parietal eminences. The beading of the ribs stands out plainly. 
The chest is narrow, retracted at the sides, and increased in the antero- 
posterior diameter, producing the so-called pigeon-breast. In pro- 
nounced cases there often is an axillary groove extending the length 
of the chest. A rare deformity is the funnel-chest, in which there is a 
marked retraction of the lower portion of the sternum, greatly decreas- 
ing the anteroposterior diameter at this point, with a corresponding 
increase in the lateral diameter. 

The epiphyses of both the upper and lower extremities are enlarged, 
and there is a decided outward curvature of the tibia. There may also 
be anterior bowing of the femur. The radius and ulna may also show 
curvature, but this is less usual. Knock-knee is present in a com- 
paratively small number of cases. 

The child has a pot-belly, often with umbilical hernia. 

Physical examination reveals a large fontanel, two or three times 
the size normal for the age. Dentition is delayed; repeatedly infants 
of a year and over will not have erupted a tooth. Craniotabes, which 
consists of soft, compressible areas in the skull showing deficient 
deposit of bone-cells, is present in many young rachitic infants. 

A non-angular posterior spinal curvature involving several vertebrae 
will be found in a majority of the patients under fifteen months of 
age. This is due to muscle and ligament weakness, and will be proved 
by suspending the child by the arms, when the curvature will usually 
disappear. This straightening may not completely take place in older 
children, in whom the deformity has existed for several months. Fur- 
ther, in older cases there may be associated lateral and rotatory 
curvatures. 

The clavicle may show thickening at the ends, and in severe cases 
I have repeatedly seen an increase in the anterior curve. 

In a large out-patient and hospital service extending over many 
years in different institutions all types of deformities have been 
presented, an enumeration or 'description of which would add nothing. 

Rachitic children will be found abnormal in other respects. There 
is usually a secondary anemia. They possess poor resistance to 
bacterial infection, and when such infection, or in fact any disease, 
occurs the chances of recovery are less than in a normal individual. 
The nerve resources are of a low order. Convulsions may occur upon 
slight irritation. The digestion is rarely up to the normal for the 
child's age. 

It is to be understood that in this description I have been con- 
sidering a well-marked case. Hundreds of children show varying 
degrees of mild rachitis in which the conditions may in no way com- 



120 THE PRACTICE OF PEDIATRICS 

promise the individual. Further, it must be appreciated that not 
every case shows the even distribution of the lesions enumerated. 
There may be cases with bowed legs or knock-knees, spinal deformity, 
or enlarged cranium, in which one of the conditions mentioned may be 
the only sign of consequence. 

Differential Diagnosis. — That confusion arises in differentiating 
rachitis from cretinism, mongolianism, and hydrocephalus is demon- 
strated in consultation practice. A clear mental picture as to what 
constitutes mongolianism, cretinism, and rachitis would eliminate 
confusion without the assistance of a consultant. A differentiation, 
however, between the large, rachitic head and one due to an acquired 
hydrocephalus or to a mild degree of congenital hydrocephalus is not 
a simple matter, for the reason that when there is hydrocephalus there 
is usually rachitis. An immediate diagnosis is impossible. I have 
known most competent neurologists to ask for time for further ob- 
servation before making a diagnosis. The further observation has 
usually included repeated measurement of the circumference of the 
child's head. A child's head increases in circumference from birth 
onward about as follows: During the first year, 4 inches, 3 inches of 
which is increase during the first six months ; during the first and second 
year, 1 inch ; during the second to the third year, H ^o % ii^ch ; during 
the third to the fifth year, 13^ inches. When the rate of growth 
considerably exceeds these figures, it is an indication of a hydro- 
cephalus. A prominent fontanel and ununited sutures indicate 
hydrocephalus. (See p. 510.) 

Prognosis. — The prognosis is favorable in so far as the immediate 
disease is concerned. Uncomplicated with intercurrent disease, all 
cases recover if properly treated. Indirectly, because of the sus- 
ceptibility to infection and the lack of resistance, rachitis is a large 
factor in the mortality of the young. Cured patients suffer no in- 
convenience in later life. There is doubtless some shortening in 
stature; it is difficult to determine the effects in this respect, as there 
are no means of knowing what height the individual might have 
attained had he not had rachitis. In women at childbirth its baneful 
possibilities are made prominent in narrow and contracted pelves. 

Treatment* — It will readily be seen, from the foregoing, that the 
treatment of rachitis resolves itself into the adjustment of the diet to 
the needs of the patient. As growth and normal development cannot 
take place without proteid and salts, and as the history of our cases 
has shown that these are the elements which are most frequently 
lacking in the diet of rachitic children, suitable feeding should be our 
first consideration. 

Diet of Infants. — Artificial foods usually are deficient in both the 
fat and proteid; therefore these foods should be discontinued. I 
have seen a vast number of cases that were on cow's-milk feeding of 
such strength that it could not be assimilated. In practically all 
cases a properly adapted cow's-milk formula is the only treatment 
required. 



RACHITIS (rickets) 121 

Diet After the First Year. — For those over one year of age not only 
should artificial food be discontinued and cow's milk given, but the 
cow's milk should be supplemented by a diet rich in nitrogen. I 
order a diet composed largely of milk, scraped beef, soft-boiled egg, 
oatmeal, and wheat gruel. After the second year purees of beans 
and peas are added to the dietary because of the large percentage of 
proteid which they contain. It is impossible to prescribe a more 
definite dietary. The physician must remember that a diet as highly 
nitrogenous as the child can assimilate is to be given. Unfortunately, 
many rachitic children cannot take cow's milk in quantities sufficient 
to make it of real nutritive value. This is often the result of an in- 
ability to digest the fat, the milk being taken without inconvenience 
when a large proportion of the fat is removed. Skimmed milk con- 
tains at least 3 per cent, of the nutritional element most desired, the 
proteid, and makes a valuable addition to the diet. If a dilution of 
the milk is necessary, oatmeal gruel should be used. 

Many children who cannot take a full milk diet will take an ounce 
or two of butter daily without inconvenience. For older children I 
advise the free use of butter, one or two ounces daily. It is advisable 
to give rachitic children a moderate amount of fat, as it aids in the 
production of heat and thus saves the tissues. Before the second 
year of age cod-liver oil is often a valuable addition to the dietary. 
In prescribing cod-liver oil I prefer to use the plain oil. In spite of 
the disgust adults have for cod-liver oil, children usually take it 
readily. The younger the child, the better the oil will be taken. 
To delicate children six months of age from 10 to 30 drops may be 
given three times daily after meals. From the sixth to the eighteenth 
month, from 20 drops to 1 dram may be given three times daily after 
feedings. After the eighteenth month, from 1 to 3 drams may be 
given three times daily after meals. 

Hygiene. — Brine baths and oil inunctions aid materially and are of 
great value in improving the child's condition as a whole. The brine 
bath (p. 780), which is given at bedtime, is followed by an inunction of 
goose-grease, unsalted lard, or cacao-butter. The goose-oil or lard is 
preferred. At least two teaspoonfuls should be rubbed into the skin. 
The benefit derived from the inunctions is largely due to the massage. 
The rubbing should be continued for at least ten minutes. The 
muscles of the back and legs should receive special attention. In a 
few instances the animal fats act as irritants to the skin and produce 
a fine, papular eruption. 

The rachitic child should have plenty of fresh air, by means either 
of a fireplace or an open window. On stormy and very cold days he 
should be given an indoor airing (p. 762), being placed in his carriage 
or cart and wheeled about the room. To avoid drafts, the window 
or windows on only one side of the room should be opened. 

Rachitic children are very susceptible to head colds and bronchitis; 
therefore, every means must be employed to prevent exposure. As 
creeping and playing on the floor are the most frequent methods of 



122 THE PRACTICE OF PEDIATRICS 

taking cold, the exercise pen (p. 767) is particularly useful in these 
cases. 

Drugs. — Drugs, in my experience, are of value only as they increase 
the appetite and the capacity for properly selected foods. The ad- 
ministration of phosphorus is without avail if the deficient diet is con- 
tinued. Specific medication without proper food and a fair digestive 
capacity is valueless. With proper food and a fair digestive capacity, 
medication is superfluous, and a child rapidly recovers without it. 

I have used phosphorus extensively, and have yet to see a single 
case in which the beneficial action of the drug could be proved. In 
giving phosphorus, the oleum phosphoratum is the easiest and most 
convenient form for administration. One drop of the preparation 
represents Jf oo grain of phosphorus. To children under one year of 
age 1 drop may be given three times daily. To those between the 
first and second year, 13^^ to 2 drops may be given three times daily 
after meals. 

Deformities. — The deformities of the osseous system, particularly 
of the spine and long bones, may be prevented — the first, by keeping 
the child on his back a greater part of the time, and, if the deformity is 
well marked, by teaching him to sleep resting on his stomach. When 
a kyphosis is present, the child should be allowed to remain in the 
upright position but a few moments at a time. 

Deformities of the femur, tibia, and fibula occur long before the 
child attempts to stand, but too early use of the legs, while not neces- 
sarily a cause of deformity, may greatly aggravate the existing condi- 
tions. For this reason rachitic children should not be encouraged to 
walk or stand until they have been under treatment for three or four 
months. 

Operative measures for the correction of bow-legs are better post- 
poned until after the third year. If corrected at an earlier period, 
the deformity is apt to return, and the late deformity may be greater 
than the original one. 

In my experience the use of the braces to correct the deformity of 
the legs has been of but little assistance, nor has any patient of mine 
been benefited particularly when so treated by the orthopedic surgeon. 
The use of braces and jackets of plaster-of-Paris in kyphosis is usually 
unnecessary. Rest, massage, and exercises directed to restoring power 
to the weakened muscles have answered well. 

THE DELICATE CHILD 

In pediatric practice one frequently meets with children who, 
while they cannot be said to be suffering from any disease or patho- 
logic condition, yet are inferior in physical development. They lack 
endurance, and possess poor resisting powers. They are usually under 
height, always under weight, and, in short, have so many character- 
istics in common that they constitute a class by themselves, and as 
such warrant our attention. 



THE DELICATE CHILD 123 

Normal Development. — The average child, at the various periods 
of early life, conforms with a certain degree of regularity to the mental 
and physical development which by long association we have come to 
regard as normal. Thus a standard may be said to have been estab- 
lished, and it is up to this standard that we expect the growing child 
to measure. This is what we look upon as the average of physical 
and mental development. A few children exceed these requirements 
and are stronger and larger at the sixth month than the average 
child at the ninth month. Again, older children at the fourth or 
fifth year may be in every way equal to their normal playmates a 
year or two older. 

Abnormal Development. — On the other hand, there are children 
who are born with reduced vitality, or who, through faulty manage- 
ment, usually in relation to feeding, acquire a reduced vitality. Semi- 
invalid adults almost invariably beget semi-invalid children. If the 
parents are of average health and of good habits and the debilitated 
condition of the child is due to faulty management and nutritional 
errors, the result of proper dietetic and hygienic management is usually 
prompt and satisfactory. With the persistently delicate, the offspring 
of physically enfeebled parents, the results are less satisfactory. 

Treatment. — By proper regulation of the habits of a delicate child, 
as regards all the details of his daily life, a far better adult is produced 
than if no such effort has been made. In other words, a diet and gen- 
eral regime of life best adapted to the individual in question will in- 
variably improve the physical condition of that individual. This 
applies to the strong as well as to the delicate, to the growing young of 
the lower animals as well as to the offspring of man. It is the poorly 
developed, delicate child that we are particularly to consider — the 
undersized, frail, small-boned child, whose appetite is persistently poor 
or capricious, who sleeps poorly, tires easily, is usually constipated, 
who is subject to catarrhal conditions of the respiratory tract, and 
whose powers of resistance generally are diminished. 

On assuming the management of one of these children it is abso- 
lutely necessary to make a thorough examination, followed in some in- 
stances by a few weeks' observation, in order to become acquainted 
with the case in its individual aspects, to learn idiosyncrasies, and to 
eliminate the factor of actual disease as a causative agent. When we 
demonstrate to our satisfaction that the child is free from such diseases 
as tuberculosis, syphilis, and malaria; when we have eliminated by 
properly directed treatment all causes, such as adenoids, otitis, phimo- 
sis, adherent clitoris, vaginitis, or parasitic and irritant skin lesions, 
which may have had a deterrent influence upon growth ; and when we 
have satisfied ourselves as to the actual condition of our patient, we are 
in a position to lay down definite rules of management. 

Every child has a distinct function to perform. As soon as he is 
born he is confronted with a serious problem — the problem of physical 
and mental growth. Inasmuch as this growth and development de- 
pend, above all things, upon a properly adapted food-supply, it must 



124 THE PRACTICE OF PEDIATRICS 

be our first step to provide such nutriment as will be most conducive 
to growth. As growth takes place in all parts of the body through 
cellular activity, the nutritive elements which support cell prolifera- 
tion must be important constituents of the diet, and among these the 
proteids are of prime importance; hence in the management of these 
children a point to be remembered in the adaptation of the food is the 
necessity of feeding as rich a proteid as the child can assimilate. The 
younger the child, the greater the necessity for growth. 

Regular Weighings Necessary. — An infant should be weighed at 
regular intervals, and if under one year of age, should not be considered 
as doing even passably well if not gaining at least four ounces weekly. 
When a baby remains stationary in weight, the development is in- 
variably abnormal. When the weight is stationary or when only a 
slight gain of one or two ounces weekly is made, we always find after 
a few weeks that there is malnutrition, in spite of the apparent gain, as 
will be evidenced by the symptoms of beginning rickets — anemia, the 
characteristic bone changes, flabby muscles, and a tendency to disease 
of the mucous membranes. Delicate infants should be weighed daily 
at first; then, as improvement takes place, at intervals of two or more 
days, but never less frequently than once a week, during the first year, 
no matter how vigorous they may become. The weighing keeps us 
directly in touch, with the child's condition, but since the increase may 
be in fat alone, an occasional examination of, the child stripped is 
necessary to tell us whether there is substantial growth in bone and 
muscle. 

Feeding Infants. — When it is demonstrated that a child will not 
thrive on the breast of the mother, another breast should be sub- 
stituted, or an adapted high-proteid cow's milk should supplement or 
replace the breast milk. If the child is bottle-fed and it is demon- 
strated that proper growth and development are impossible on cow's 
milk, on account of proteid incapacity, then a wet-nurse should be 
secured. 

When, after the first year, more liberal feeding is allowed, the neces- 
sity for a high proteid in the food selected is as urgent as before. This 
applies to those children who are brought to us showing evidences of 
late malnutrition, as well as to those whom we have had under our care 
from early infancy. 

An important element in the diet up to the third year is milk. A 
child from the first to the third year ought to receive one pint of milk 
daily. Unfortunately, many debilitated children have a very poor 
capacity for fat assimilation. When given full milk in as small an 
amount as one pint daily, they often develop foul breath, coated 
tongue, and loss of appetite, or they suffer from frequent attacks of 
acute indigestion. The milk is necessary, not because of the fat, 
which can easily be dispensed with, but because of the high percentage 
of proteid which it contains — from 3 to 4 per cent. When this fat 
incapacity exists, the milk is said to "disagree," although skimmed 
milk will be taken without inconvenience. Enough sugar may be 



THE DELICATE CHILD 125 

added to bring the percentage up to seven, in order that the extra 
sugar may replace the fat for fuel. Skimmed milk with sugar added 
furnishes a food of no mean order. Too much milk, however, must 
not be given. When more than one quart daily is taken, the desire for 
more substantial nourishment, such as eggs, meat, and cereals, is 
removed. 

Diet After the First Year. — At the completion of the first year, keep- 
ing in mind a high proteid we may give scraped beef, at first one tea- 
spoonful once a day, in addition to the cereal and milk. If the beef is 
well borne, and it usually is, a teaspoonful may be given twice a day, 
and later three times a day, immediately before the bottle-feeding. 
Eggs should be brought into use from the twelfth to the fifteenth 
month. At first one-half an egg, boiled two minutes, is given mixed 
with bread-crumbs. If well borne, a whole egg may be allowed. The 
cereals used should be those richest in vegetable proteid, such as oat- 
meal, containing 16 per cent, of proteid, dried peas, with 20 per cent, 
of proteid, and dried beans, containing 24 per cent, of proteid. The 
peas, beans, and lentils should be given in the form of a puree. 

If the child during the second year has an indifferent appetite, the 
quantity of milk should be reduced, never more than one pint of 
skimmed milk being permitted daily for the first week or two. Many 
delicate children who apply for treatment after the first year of age 
have been subjected to as grave errors in diet as are seen among the 
bottle-fed. Starch and milk frequently furnish the only nutrition 
up to the fourth or fifth year, the starch used being generally in the 
form of bread, crackers, and ill-cooked cereals. In one case four 
quarts of milk were taken daily by a boy of seven years. 

In dealing with this class of children — the delicate, undersized, 
slow-growing class — it is our aim to give as liberal nitrogenous nourish- 
ment as is compatible with the digestive capacity of the patient. If, 
however, the child has had rheumatism, or if there is a tendency to 
lithiasis, the use of a large amount of meat is contraindicated. For 
such children the high-proteid cereals are particularly valuable. In 
general, from early life the diet of the delicate child should consist of 
milk, suitably adapted, with highly nitrogenous cereals added when 
permissible. Many delicate children of the ''runabout" age who can- 
not digest milk containing 4 per cent, of fat will easily digest butter- 
fat spread on bread or potatoes. In this way I often use butter to 
supply fuel to act as a proteid-sparer. Oatmeal-water, or oatmeal 
jelly, mixed with the milk should be ordered at the seventh month. 
When age allows, the addition of rare meat, poultry, eggs, and purees 
of dried peas, beans, and lentils should be made. Boxed, ''ready to 
serve" cereals are never given; raw cereals are provided which are 
cooked three hours. While a high-proteid diet is desirable, other foods 
are necessary. Green vegetables, animal fats, the ordinary cereals, 
cooked and raw fruits, are required to furnish the necessary acids and 
salts, as well as the necessary variety. In short., the ideal diet for a 
delicate child is that combination of foods which, while imposing 



126 THE PRACTICE OF PEDIATRICS 

the least burden upon the digestive organs, suppUes the body with. 
material sufficient for its needs. (See dietary, p. 105.) 

Baths. — On account of the fear that a delicate child may take cold, 
the bath is often omitted. All children, both the well and the delicate^ 
after the second week should be tubbed daily; the delicate particularly 
require bathing. The salt bath (p. 780) is usually advised. The best 
time for giving the bath is at bedtime, and in order to avoid all chance 
of exposure the temperature of the room should be elevated to 80°F. 
The temperature of the water may vary. It should never be above 
95°F. except for very delicate young children in whom there is a 
tendency to a subnormal temperature. Even in these cases the tem- 
perature of the bath should never be higher than the temperature of 
the body. For the frail and the very young, the bath should not be 
continued over five minutes. In bathing children of eighteen months 
or over, if the physical conditions allow, a distinct advantage will be 
gained by a reduction of the temperature of the bath while the child is 
in the water. An immersion in water at 90°F., followed by a gradual 
reduction during the space of five or six minutes to 70°F., should, upon 
brisk rubbing, be followed by quick reaction. For children after the 
third year, a graduated cold spinal douche has served me well. (See 
Spinal Douche, p. 779.) If the reaction is not good, if the extremities 
are cold and are slow in becoming warm, the reduction in the tempera- 
ture should be less or none at all. With the very poorly nourished, a 
reduction below 80°F. should not be attempted. Following the drying 
process, primarily for the benefit of the massage, goose oil, unsalted 
lard or olive oil should be rubbed into the skin over the entire body for 
five to ten minutes. The bath and massage inunction, besides favor- 
ably influencing nutrition, are very effective in inducing sleep. 

Fresh Air. — Delicate children are usually deprived of a proper 
amount of fresh air, for the same reason that they are insufficiently 
bathed — the fear of making them ill. All children need an abundance 
of fresh air both in illness and in health. To the delicate fresh air is 
even more essential than to the robust. As many hours daily as 
practicable should be spent out-of-doors. The time thus spent de- 
pends upon the season of the year and the residence of the child, 
whether in the city or the country. In the city, during the colder 
months with pleasant weather, the child should spend at least five 
hours daily in the open air, dividing the day into two outing peuods — 
from 9 to 11.30 in the morning and from 2 to 4.30 in the afternoon. 
On very cold days (20°F. or below), on stormy days, and on days with 
very high winds, the child should be given his airing indoors. He is 
dressed as for out-of-doors, placed in his carriage, and left in a room, 
the windows on one side of which are open. Not infrequently during 
February and March delicate children will be prevented from going 
out-of-doors for several consecutive days. If some means for a daily 
systematic indoor airing is not provided, these children will often go 
backward, no matter how excellent the other management. The 
first symptoms are loss of appetite and the ability to assimilate food. 



THE DELICATE CHILD 127 

In my private work among athreptics, the child is placed in the baby- 
carriage or in a basket and allowed to rest before an open window for 
ten or twelve hours of every twenty-four, with a hot-water bottle at 
his feet. Here he is fed, being removed only temporarily to warmer 
quarters for a change of napkins. I have three roof-gardens in opera- 
tion. A boy patient, nine months of age, was taken to the street 
only once in four months, then only going to church to be baptized. 

Sleep. — The delicate child requires no more sleep than does the 
strong, and the rules governing this function at the various periods of 
hfe are the same both for the strong and for the weak. (See Sleep, p. 
45.) The sleeping-room of the delicate child should always communi- 
cate with the open air by a window, either directly or through an 
adjoining room. A satisfactory means of ventilation is the window- 
board (p. 138). The child should occupy the room alone, if possible, 
sharing it neither with an adult nor another child. This ruling applies 
to all ages, but is particularly necessary after the second year. 

The Nursery. — The temperature of the nursery, day or night, should 
never be above 70°F. during the colder months. Very young infants, 
and those who are with difficulty kept covered, should not sleep in air 
below 65°F. 

Delicate children of the ''runabout" age are very susceptible to 
colds. In the management of such children it is necessary to use every 
precaution against exposure. The most frequent way of exposing a 
child to cold is by allowing him to sit on the floor. To keep the 
child of ten months to three years of age off the floor during the winter 
months, and thereby to eliminate this means of exposure, is very diffi- 
cult. In fact, with active children learning to walk, or who have just 
learned to walk, it is practically impossible under the usual conditions. 
During the colder months there is always a current of cold air near the 
floor, and allowing the child to creep in winter, even if the floor is pro- 
tected by rugs and carpets, is one of the surest ways of permitting him 
to take cold. If he is not allowed to walk on the floor, he is very sure 
soon to sit down. If he is not allowed to creep and walk about at will, 
he will not get the proper exercise and will show faulty development. 
For such cases, I have found the exercise pen of immense service. 
(See p. 767.) After being dressed, washed, and fed, the child is placed 
in the pen, on a rug if desired. Toys are given him and the door is 
closed. He can now roam about at will, stand up, sit down, creep or 
walk without the slightest danger from drafts. 

Influence of Climate. — Much has been written regarding the influ- 
ence of climate in the type of case we are considering. According to 
my observation, this matter does not deserve the attention it has re- 
ceived. The city child in a well-to-do family is, as a rule, better off for 
eight months of the year in his own home with its usual conveniences. 
The benefits attributed to change in climate are usually the result of a 
change not of climate, but to more fresh air, which is afforded by the 
larger rooms of the hotel, with its loosely constructed doors and win- 
dows; and the fact that, since the parent is desirous that the child shall 



128 THE PRACTICE OF PEDIATRICS 

receive the full benefit of the change, he is kept in the open air for a 
much longer time than when at home. The air at such a place is more 
expensive, and consequently more appreciated than the air at home. 
With sufficient heat and proper ventilation, we may make our own 
climate. It is not to be denied, however, that a change of residence 
for a few weeks, during March and April, from New York to Lake wood 
or Atlantic City, is sometimes of advantage. 

From the first of June to the first of October the delicate child should 
not remain in any large city if removal is possible. The humidity and 
the heat which may prevail for protracted periods during this time 
render the city unsafe, particularly during July and August. The 
seashore for the entire summer is not to be advised. The children 
whom I have sent inland to the country and to the mountains have, as 
a rule, returned in the autumn in much better physical condition than 
those who spend the summer by the sea. 

Clothing, — Thin, poorly nourished children require more clothing 
than do those physically normal. A fairly good index as to whether 
a child is sufficiently clad is the condition of his lower extremities. The 
forearm and hand cannot be relied upon. The legs and feet of every 
child should always be warm to the touch. 

As clothing, a mixture of silk and wool next to the skin is most 
desirable. Although less desirable, a mixture of wool and cotton may 
be used. The linen mesh, often useful for the vigorous ^'runabout," 
is not to be advised for the delicate. 

Exercise. — Exercise is to be encouraged, but should never be allowed 
to the point of fatigue. In large cities all delicate "runabouts" from 
three to five years of age should be allowed to walk not more than six 
blocks in going to the playgrounds. If the distance is greater, the 
child should ride part of the way, play or walk for a time, and then be 
placed in the carriage or cart and ride home. Younger children, two 
to three years of age, should be wheeled both ways and taken out at 
the park for a run when the weather conditions permit. 

Midday Nap. — Every day after the midday meal the child, regard- 
less of age, whether two years or six, should be undressed and put to 
bed for two hours. He should be left alone in the room, and whether 
he sleeps or not he should remain in bed for the two hours. 

Entertainment. — Entertaining play is necessary, but every kind of 
excitement, such as children's parties, emotional plays at the theater, 
and rough play with older children, should be avoided. 

Now and then I meet with a case among the well-to-do in which, 
because of prolonged faulty feeding or vicious heredity, the vital spark 
is so low that, fan it as we may, no impression upon it is made. As a 
rule, these stubborn cases are the offspring of alcoholism and de- 
bauchery. The patients are thin, anemic infants; they develop into 
thin, anemic children, and into thin, anemic adults. The delicate 
and degenerate are found in all the walks of life, but they are especially 
numerous in dispensaries and in children's institutions. 

Much of the work of the pediatrist is with the weakly of the so- 



THE DELICATE CHILD 129 

called " better class /^ His success in the management of these delicate 
children depends largely upon the home cooperation, and a promise 
of this should be obtained before taking the case. The parents must 
be taught that the development of the intellect, the character, and 
the body go hand in hand and that a vigorous intellect is rarely found 
without a vigorous body. They must be convinced that the body 
is more than a machine. It has delicate organs to keep in repair and 
supply with energy. It has a nervous organization; it has sensibilities. 
The normal exercise of all these functions demands the normal nourish- 
ment of the body. In my experience, family cooperation in a few 
instances has been difficult to obtain. The parents began well, but 
soon tired of the extra work required. The care of the young has 
always been undertaken in such a wretched, unscientific manner that 
it is difficult to make the untrained mind appreciate the necessity of 
careful attention to details in management. 
9 



IL EXAMINATION AND DIAGNOSIS— CARE OF ACUTE 

ILLNESS 

DIAGNOSIS 

Before a student in diseases of children is shown a sick child, he 
should be made thoroughly familiar with the normal child of approxi- 
mately the following ages : under three months, one year, three years, 
five years, and ten years. 

He should learn the normal appearance of the eyes, ears, throat, 
skin, genitals, and the character of the stools of the various ages. He 
should be instructed in the examination of the liver, spleen, abdomen, 
heart, and lungs 

In teaching diagnosis in children in postgraduate work, covering 
a period of twenty- six years, I have repeatedly been impressed with 
the handicap under which many physicians work because of a very 
indifferent conception of the normal. 

Without sufficient ability to examine the canal and drum of the 
ear, and to know the possibilities for variations within the normal, it 
it futile to attempt the recognition of diseased processes. 

Many physicians expert in pulmonary diagnosis in adults are 
wholly unable to make out even approximately diseased conditions 
in the lungs of infants and young children. These are all conditions 
that cannot be taught in a didactic way. Neither can one learn much 
of the subject through reading. What is required is the examination 
of the normal infant or young child — not a few examinations, but a 
very careful routine examination of many infants and young children. 
A point most difficult to determine is the borderland between normal 
and diseased processes, as evidenced by physical signs. 

Diagnosis in children requires ability to estimate the condition 
as a whole. The fact that the patient cannot describe his symptoms 
is of more advantage than detriment. The child appears in the 
perfectly natural condition, without attempt to mislead, with no 
preconceived ideas or theories. In other words, the child, unless 
alarmed, is always natural, always himself; this is a very definite aid. 
Further, the young child has no imagination. He is never hypo- 
chondriac. Instead of giving the impression that he is more ill, he 
is liable to be judged less ill than he really is, because of his activities 
and disinclination to give up. This tendency to remain active may 
be misleading. When, therefore, a child appears very ill, while the 
condition may not be dangerous, we may always know that he feels 
very badly. 

Physicians who wish to become expert in diagnosis must first 
learn the normal child from birth until he passes into the adult. 

130 



DIAGNOSIS 131 

Diagnosis by Inspection 

We must learn the appearance and bodily habit of the child under 
normal conditions. Thus the baby of a few weeks cries when hungry, 
and with incoordinate movements of the arms and legs expresses his 
discomfort. With colic or pain of any nature he also cries, and with 
incoordinate movements of hand and legs makes known his discom- 
fort. But the child's manner of crying and the movements of the 
body are in no way alike. A baby spoiled and who wants to be taken 
up also makes a great ado, and yet he acts vastly different than when 
he is in hunger or pain. 

All the above manifestations are vastly different from the cry and 
the arhythmic movements of early meningitis. 

The position in which the child rests in bed often supplies us with 
very good evidence as to the nature of the trouble. Thus one posi- 
tion is assumed in meningitis; another in paraplegia; and another in 
scurvy or poliomyelitis. The countenance or the facial expression 
may be indicative of the disorder. The anxious, flushed countenance 
of acute pneumonia, with the dilatation of the alse nasi and the rapid 
breathing and grunt, are all strongly suggestive. The sunken eyes, 
the expressionless countenance, the ashy pallor, the superficial breath- 
ing, all characterize the appearance of the patient with intestinal 
toxemia. 

The diagnosis of malnutrition and marasmus is always stamped on 
the countenance. In cretinism, in Mongolian idiocy, in micro- 
cephaly and other forms of mental deficiency, the name of the dis- 
order is written on each countenance, and for diagnosis we need go 
little further. 

The blue-white skin of anemia, the pallor of nephritis, with the 
fulness about the eyes, are often diagnostic in themselves. Among 
the transmissible diseases, measles, mumps, and chicken-pox, are 
readily diagnosed by inspection. In scarlet fever, also, inspection 
is our greatest aid. 

In hemiplegia the quiet arm and leg, with the other arm and leg 
in motion, are strongly suggestive as to the nature of the trouble. 

The only way in which whooping-cough may be positively diag- 
nosed is to watch the child during a paroxysm. 

By inspection we can fairly accurately determine the existence of 
acute laryngitis or membranous laryngitis. As mentioned elsewhere, 
the obstruction in acute laryngitis is inspiratory, while in membranous 
laryngitis it is both expiratory and inspiratory. 

The position of the head, the dysphagia, and the peculiar cracked 
voice mark retropharyngeal abscess. The method or peculiarities of 
locomotion supply most valuable evidences of Pott's, hip or other 
bone and joint diseases. In tetany, the ''accoucheur's" hand, and 
the feet in extreme extension, are all that are necessary for diagnosis. 

The yellow conjunctivae and the tinted skin indicate jaundice. 
In the skin diseases or skin manifestations of any nature inspection 
again is an important means of diagnosis. 



132 



THE PRACTICE OF PEDIATRICS 



The facial expression due to adenoids is so characteristic that every 
text-book contains a photograph demonstrating the ''adenoid face." 

Laryngismus stridulus, convulsions, tonsillitis, rachitis, scurvy, and 
stomatitis are all diagnosed by inspection. 

It will readily be seen what a great aid in diagnosis is possessed by 
the physician who possesses trained powers of observation. 

Inspection During Sleep. — It is of advantage to observe many 
children when they are asleep, and beyond all the influences of their 
surroundings. In not a few cases correct respiratory observations are 
possible only when the child is asleep. 

FIRST EXAMINATION 

Upon being called upon for the first time to see a patient, it is my 
custom in every case to take a history. Below is a copy of the history 
record which I use. Form A represents the front of the slip. Form 
B represents the back of the same slip. Further records are kept on 
plain ruled sheets of the same size — 5 by 8 inches. 

HISTORY RECORD 



FORM A 




Date Address Name 




Mr. Age 




Pamily History Children living Ch. dead Cause 


Rheumatism Tuberculosis 


Syphilis 


Nervous Dis. Alcohol, tea, etc. 


Miscarriages 


Personal History child, born at Labor Wt. at B. lb. 


Sat up at mo. Talked at mo. Teeth at 


mo. Walked at mo. 


General Health and Habits 




Appetite Eats between meals? 


Tea, beer, etc.? 


Bowels Bath 


Fresh air 


Sleeps from to ; and from to 


. Snores? Mouth Br.? 


Previous Diseases Meas. Wh. Cg. C-Pox 


Scarlet. Diphth. 


Mumps. Sm-Pox. 




Gastro-enteric 




Respiratory 




Ear Throat 


Colds 


Diet from Birth Nursed 




Present History 




FOftM B 




EXAMINATION 




Weight lb. Height in. Circ. Head 


in. Circ. Chest in. 


General Condition Color Muscles Reflexes 


Mentality Sits? Walks? 


Talks? 


Head Fontanel Sutures 


Cranio-tabes 


Eyes Nose Disch. 


Breathing 


Mouth Tongue Muc. Memb. 


Teeth 


Throat Tonsil 


Adenoids 


Lymph Nodes Ears 


Epitrochlears 


Thorax Shape Rosary 

Heart 

Lungs 


Groove 




Abdomen Umbilicus 


Liver Spleen 


Genitals Skin 




Extremities Epiphyses Contour 


Feet 


°.P. .R . Blood R.B.C. 


Hb. %. W.B.C. 


Urine React. S. G. Alb. S. Ind. Ace. 


Mic. Exam. 



ESSENTIALS IN THE CARE OF ACUTE ILLNESS 133 

When the history is completed, the leaves are placed in a Moore's 
loose-leaf binder. 

The patient's family history is carefully taken. The habit of ob- 
taining a complete and accurate record of family peculiarities in rela- 
tion to disease is often of much service, subsequently, if not at the 
time. Only upon systematic questioning will necessary facts be 
brought out relating to tuberculosis, rheumatism, syphilis, etc. The 
child's personal history includes the birth-weight, the rate of growth, 
the nature of previous illnesses, present weight, the condition of the 
skin, eyes, nose, heart, lungs, tongue, bowels, bones, and the tem- 
perature. All these points are noted and recorded. It is only by 
such an examination, requiring much time and patience, that we 
are able to become thoroughly acquainted with the case in hand. 

The child must be stripped for the examination, when the condi- 
tions found are entered in the proper spaces in the history chart. 
After the family history has been taken and the general physical 
examination is completed, we are in a position to devote ourselves 
to the present condition of the patient. After one has practised fo,r 
a time, thoroughly examining every new case, he is impressed not 
only with the value of the method as bearing upon the management 
of the condition in question, but also with the unexpected pathologic 
findings in other organs, particularly the heart, throat, and lungs. 

ESSENTIALS IN THE CARE OF ACUTE ILLNESS 

Our first intention, in our relation with a sick child, regardless of 
the nature of the illness, is to appreciate the changed conditions which 
exist. A well child, regardless of the position he may occupy in the 
social scale, subscribes to a certain living regime, which should be so 
fashioned as to supply the requirements of nutrition and healthy 
growth, which means normal development. Thus, he is fed, clothed, 
and has the benefit of fresh air, exercise, and bathing. When the 
child becomes ill, his position temporarily is changed, and in order 
for us to act to his best interest, radical changes must be instituted 
in order to meet this changed condition as regards appetite, sleep, 
the digestive capacity, and quiet. The great majority of the serious 
illnesses in children are acute in character. Every child begins the 
illness with a definite number of strength units. Vitality and re- 
sistance determine in no small degree the issue of the disease. We 
must so act as to conserve every strength unit. 

Our first duty, then, toward the sick child is to place him in the 
most favorable position, in order that he may be able to withstand 
the ordeal through which he must pass. Regardless of the nature 
of the disease, certain requirements must be fulfilled that apply to 
all severe illnesses, the general management of which in children is 
very similar. 

Patient to be Kept in Bed. — The patient is to be kept in bed, not 
held on the lap. The handling of the patient, the passing from one 



134 THE PRACTICE OF PEDIATRICS 

person to another, the attempt at entertaining, cause active excitement 
and waste energy, when quiet is necessary. 

Quiet Attendants. — Attendants who are quiet and agreeable to 
the child should care for him. In my seriously sick cases — pneu- 
monia, endocarditis, and the like — I allow but one person, and that 
the attendant, in the room at one time. 

Clothing. — The clothing should be the usual night-clothing, to 
which the patient has been accustomed in health. There is no illness 
that requires extra clothing for the body when the customary room 
temperature (66° to 68°F.) is allowed. Heavy shirts and oiled silk 
or cotton-wool jackets are never to be employed, regardless of the 
nature of the illness. 

In summer the lightest clothing should be used ; for younger 
children a thin linen slip with the addition of a napkin is all that is 
required. 

Sponging. — The patient is sponged over once or twice a day for 
cleansing purposes, regardless of the nature of the illness. During 
the hot days of summer the sponging may be repeated several times 
with advantage. There is no disease of childhood in which the appli- 
cation of water to the skin is a dangerous procedure. On the con- 
trary, it is quite necessary that the skin be so treated that it functionate 
actively. 

The Sick-room. — In summer, a cool, quiet room, large if possible, 
with wide-open windows, or its equivalent out-of-doors, should be 
selected for the patient. During the colder months a generous air 
space is most desirable. 

Room Temperature. — In winter the thermometer should never 
go above 70°F. Hot, ill-ventilated rooms depress the vital powers. 
The child is poisoned by carbonic dioxid; he is made restless and 
irritable. He uses up nerve force and energy is wasted. A room 
temperature of 66° to 68°F. is best under most) conditions. There 
are few households which cannot have a thermometer. 

Ventilation. — There must always be a communication between 
the sick-room and out-of-doors. A convenient means of ventilation 
is the window board (p. 138). 

Cold Air. — I am not inclined to advocate cold air to the extreme 
degree advised by some. A wide-open window during illness, such as 
convalescence from acute pulmonary disease, I consider an excellent 
measure if the child is suitably protected by a hood and an extra 
outer garment. When possible, I give the patient the advantage of 
two rooms, one for use during the day and one for the night. This 
is of particular advantage in grip and in the respiratory diseases in 
which there is a possibility of reinfection. The room which is not 
occupied should be aired continually.. 

Drinking of Water. — There is no illness of childhood in which 
water to drink should not be given freely. If there is any question 
as to its purity, it should be boiled. 



ESSENTIALS IN THE CARE OF ACUTE ILLNESS 135 

Diet. — The digestive capacity of every sick child is lessened; this 
we all appreciate, the degree of incapacity depending largely upon the 
severity and nature of the illness. In every illness the food strength 
should be lessened. This we do not all appreciate. For breast-fed 
babies this is done by giving water, sugar-water, or some cereal 
decoction, as barley-water, before each nursing, usually from two to 
three ounces. This dilutes the mother's milk. The nursing baby is 
satisfied when his stomach is full. He needs as much fluid as usual, 
but is unable to digest the usual amount of breast milk. For the 
bottle fed, the food strength is reduced by substituting water for a 
given quantity of the milk mixture. A safe rule to follow is to reduce 
the food strength one-half by the addition of water. If the illness is 
a very severe one of intestinal disorder, whether typhoid fever or 
summer diarrhea, milk is discontinued absolutely, and usually cereal 
decoctions are substituted. During a very severe attack of pneumonia 
or scarlet fever the milk given is diluted with cereal gruels. When 
the usual feeding is continued, gastro-intestinal infection is sure to 
add to the burden of the patient through toxins absorbed from the 
putrefaction of undigested milk in the gut. The resulting tympanites 
is a very serious feature in respiratory and cardiac diseases. Tym- 
panites embarrasses the action of the overworked or diseased heart 
and interferes with respiration already sufficiently obstructed by the 
processes in the lungs or in the pleural cavity. The carbohydrates 
leave no by-products to be eliminated by the kidneys, thus lessen- 
ing the work of these diseased organs, and perhaps preventing their 
involvement in such diseases as scarlet fever and diphtheria, by dimin- 
ishing the amount of irritation to which they may be subjected. In 
short, we must allow just as much food as the patient can care for. 
When we give more, we diminish the chances of recovery through 
added toxemia or by interfering with the vital processes. 

Needless Interference. — Regardless of the nature of the severe 
illness, we must conserve vitality by disturbing the patient as little 
as possible. The various attentions to the child should be given at 
distinct, but reasonably long, intervals. It is rare that a child will 
need food or medication oftener than once in two hours during the 
night — three hours answer in most cases. Food and medicine may 
be given at the same time. Not infrequently I see cases in consulta- 
tion where something is being done to the child every hour in the 
twenty-four. This would exhaust any well child. WTiat can the 
effect be upon the very ill, but to diminish chances of recovery? 

Urine Examination. — Nephritis is a complication, and a serious 
one, that may be looked for in all acute diseases of children. An early 
recognition of this complication is most important. Albumin in the 
urine is one of the earliest signs of nephritis, and involvement of the kid- 
neys may be discovered by urine examinations before any of the other 
signs of nephritis appear. It is my custom, in scarlet fever and diph- 
theria, diseases peculiarly liable to nephritic involvement, to examine 
the urine daily^ — in other acute diseases with fever, at two- or three-day 



136 THE PRACTICE OF PEDIATRICS 

intervals. This e^^amination is simplified by writing a prescription 
for an ounce of nitric acid (c. p.) and a few test-tubes, which are kept 
in the sick-room. The cold test is sufficient to detect the smallest 
trace of albumin. When the physician must carry the urine with him 
or have it sent to his home, the examination is sometimes postponed 
or otherwise neglected. 

Bowel Function. — Every nurse or mother is given a standing order 
that there is to be one evacuation of the bowels daily, and if this does 
not occur naturally, an enema is given. 

Bowel Feeding. — In conditions of collapse in any illness, in coma 
and certain gastric disorders particularly, sufficient nutrition cannot 
be given by the stomach. When such a condition obtains, regardless 
of the illness, we must resort to colonic feeding (p. 83). 

Suppression of the Urine. — Suppression of the urine is not an 
unusual occurrence in pediatric practice, and may occur in a wide 
range of diseases. One of our most successful means of combating 
this condition is the use of colonic flushings (p. 795). 

Pyrexia. — High temperature in children, regardless of the nature 
of the illness, is to be managed by the same methods. The most satis- 
factory in my hands has been the abstraction of heat through the 
means of hydrotherapy, in the use of sponging and packs. It is a 
popular belief among laymen that cold should not be used in scarlet 
fever or measles because of some unfavorable influences exerted on the 
rash. There is no disease of childhood with temperature in which the 
application of water to the skin does harm. I use spongings and packs 
in scarlet fever exactly the same as in pneumonia or typhoid fever. 

When is elevation of the temperature to be interfered with? What 
are the indications that necessitate interference? When we have a 
degree of temperature that causes restlessness, loss of sleep, rapid 
heart action, with resulting loss of vitality — i.e., wasted energy- — then 
I believe that means for reduction should be instituted. This will be 
necessary in some patients at 103°F.; in others, at 105°F. In other 
words, we should be governed largely by the effects of the temperature 
upon the individual and not by the reading of the thermometer. If 
sponging is employed, I use one part alcohol with three parts of water 
at about 80°F. The skin is repeatedly moistened with the solution, 
which is allowed to evaporate. In some patients such a procedure is 
soothing. In others it occasions no little annoyance, in which event 
it must not be used. By far the most satisfactory hydrotherapeutic 
procedure consists in the use of the pack (p. 777). 

Drugs. — Regardless of the nature of the disease, a full dose of castor 
oil is of benefit at the beginning of the illness. 

When drugs are used, it is essential that no harm shall result. 

In any illness in a child one requirement is to keep on good terms 
with the child's digestive tract. In our medication we must seek to 
protect the stomach. This may be done by giving much of the medi- 
cation after meals, using it by preference in capsule, powder, or tablet; 
when administered between meals, it is to be given well diluted with 



THE SICK-ROOM 137 

water. When liquid medication is necessary, elixir simplex in small 
amount is employed as a flavoring medium. Useless syrups are to be 
avoided. The worst possible custom, to my mind, is the using of heavy 
syrups for flavoring. The practice of giving the ammonia salts and 
ipecac, usually with syrup of tolu, to a child with severe bronchitis or 
bronchopneumonia is wretched; and this is putting it mildly. 

Stimulation. — I have two criticisms of general application as relates 
to the management of sick children. The first is that heart stimu- 
lants are used too early and in too large dosage, and that antipyretic 
measures are resorted to when such management is not called for. 
I have already referred to the latter in stating that a child should 
not necessarily have antipyretic measures used because he has fever 
with pneumonia, typhoid, or scarlet fever. Neither does he require 
stimulation because he has typhoid or scarlet fever or pneumonia. 
Regardless of the nature of the illness, our choice of stimulants is very 
much the same, and our reason for using them is exactly the same — 
to assist a heart that needs help. The employment of heart stimulants 
will be discussed in detail under proper headings in the different 
chapters. 

It will be seen, from the foregoing, that the treatment of different 
diseases of children has many features in common, and these essentials 
must be appreciated by every man in order that he do the best work 
in treating children. 

If there is one thing that has been impressed upon me in an active 
life of twenty-eight years in children's work, it is the necessity of com- 
pleteness of detail in our management. We little realize how sensitive 
the sick child is, how all nervous effort, all untoward influences, cost 
something. They cost energy and output of vitality which may be 
sufficient to determine the issue for recovery or against it. Family 
cooperation is necessary for success, and will be best obtained through 
the confidence and affection engendered by thorough, painstaking 
work on the part of the physician. 

THE SICK-ROOM 

If there is a choice of rooms for the patient, the size of the room 
and the means of ventilation are important points to be considered in 
the selection. During cold weather a room with southern exposure, 
to which the sun has free access, should be chosen. During the hot 
months of summer, however, the cooler the room, the better, provided 
the size and ventilation are satisfactory. The furnishings should be of 
the simplest, only those articles being allowed to remain which are re- 
quired for the patient. So many of the ailments of childhood are of 
an infectious nature that only such articles of furniture as can be 
washed should be used. Curtains, hangings, and plush furniture have 
no place in a sick-room. A plain wooden floor is much better than a 
carpeted one. Enameled beds and plain wooden or enameled chairs 
and tables are best. A painted wall is much better than a papered one. 



138 THE PRACTICE OF PEDIATRICS 

A fireplace is desirable not only for heating purposes, but also for ven- 
tilation. The successful treatment of severe illnesses in children is 
often determined by careful attention to every detail in the care of the 
patient. A child ill in a dirty, badly ventilated, overfurnished, over- 
heated room is from the first at a decided disadvantage. 

The Window-board. — A convenient and simple means for ven- 
tilating the living-room, sleeping-room, or sick-room of a child in 
cold weather is what is known as the window-board. A plain inch 
board is sawed the width of the window-frame and placed under the 
raised window in the lateral frame groove, resting upon the sill. This 
raises the top of the lower sash above the bottom of the upper one, leav- 
ing a space between, through which the air enters with the current 
directed upward. The board may be of any width — four, six, or eight 
inches. A width of six inches is commonly used. There are various 
ventilating devices in the market. Those that are of value are ex- 
pensive, and their effectiveness over the simple means above suggested 
does not warrant the expenditure. 

NECESSITY OF METHOD IN THE MANAGEMENT OF CHILDREN 

During my work in pediatrics among all types and classes of people, 
I have been particularly impressed with the fact that some children are 
the source of an immense amount of trouble, while others of no better 
health or greater strength cause very little anxiety on the part of their 
parents. Children differ greatly as regards individual traits and dispo- 
sition, but these can be fashioned to a great extent by proper manage- 
ment. The more spirited the child, the greater need of method in the 
care. I know mothers who are worn-out, nervous wrecks for no other 
reason than a lack of system in the management of the daily life of their 
children. Thoroughgoing, conscientious mothers they may be, but 
they represent that large number of mothers who have never been 
taught that certain functions and duties should be performed only at 
certain definite times every day. This subject is considered not from 
any moral standpoint but simply because of its bearing upon health. 

Beginning at birth, the baby should be fed or nursed at definite 
times and at no others. Sleeping should never interfere with the nurs- 
ing hours. The child should have time for undisturbed repose, and 
a midday nap should be insisted upon until the end of the sixth year. 
The definite time for meals, with properly selected food, should be 
continued throughout adolescence. The child should be bathed 
at a certain hour and aired at a certain hour. ''Runabouts" should 
have their hours for play and should retire at a definite time every 
evening. Such a regime is conducive to perfect health, consequently 
to better growth and development and to a stronger manhood. It is 
idle to say that many parents, particularly among the poor, cannot con- 
form to such requirements. The poor are just as anxious to do the best 
for their children as are the rich, and will do this to the best of their 
ability if reasons are explained to them. If they cannot reach the ideal, 



TREATMENT OF THE INDIVIDUAL 139 

they will attain to a higher degree of efficiency by striving. The 
trouble ordinarily is not with the mother, it rests more with the medical 
adviser, who is largely responsible for the ignorance of the mother and 
the resulting harm to her offspring. 

TREATMENT OF THE INDIVIDUAL 

In these days of specialization, in associating with medical men 
in consultation or otherwise, one is sometimes impressed with the fact 
that there is a tendency for the patient, the individual, to be lost sight 
of, to be overshadowed by the immediate disease or condition from 
which he may be suffering. In children the success of the treatment in 
practically every chronic ailment depends upon the vitality of the 
individual patient and his powers of resistance as a whole, to a much 
greater degree than is the case with the adult. The object of taking up 
this subject is not to be unkindly critical, but to call attention to one 
phase of the management which is not sufficiently appreciated by 
many who have to deal with children in their professional work. Not 
at all infrequently, poorly conditioned children, who have been treated 
for months by local measures for a skin affection, recover without any 
local treatment whatever (other than an attempt perhaps to relieve 
the itching) when their lives are ordered according to the requirements 
of the growing child as regards nutrition, bowel evacuation, sleep, 
suitable clothing, fresh air, and rational exercise. I have seen cases 
of chronic rhinitis and bronchitis which had persisted for weeks respond 
promptly when local measures, sprays and douches, and the internal 
use of drugs was suspended and the child's life was directed along ra- 
tional lines. Those who treat tuberculosis and chronic bone diseases, 
chronic otitis, chorea, and hysteria, are to be reminded that their work 
is not half finished when they have directed the usual daily or weekly 
routine treatment. In these chronic ailments it is folly to expect what 
a cure really means (a constructive process) on a destructive diet and 
improper habits of life. Children possess marked recuperative powers, 
and the rapidity of progress toward recovery is often most gratifying 
when right conditions are instituted as relates to these fundamentals 
in child management; viz., food, sleep, clothing, and bathing. It is the 
height of folly to give children iron for anemia and allow them every 
form of indiscretion in diet. It should always be remembered that 
the best results are obtained in the treatment of a child, whatever the 
nature of his illness, when he has a child's normal existence, and it is 
only under such conditions that satisfactory results of treatment can 
be expected. 



IIL DISEASES OF THE NEW-BORN 

PREMATURE AND CONGENITALLY WEAK INFANTS 

Comparatively few infants born before the completion of the 
twenty-eighth week of pregnancy survive the first year. Reported 
cases of survival of those born before that time are usually unreliable, 
as the reports seldom follow the child beyond the third month. The 
prognosis is influenced by the factors causing the premature birth. 
If syphilis is present, the child may survive but a day or two. Children 
whose births are forced because of kidney disease in the mother do not 
appear to do as well as others. In children's institutions I have treated 
a large number of premature infants and have had anything but 
brilliant results with them. They not infrequently live to be two, 
three, or four months of age or older, but on account of reduced vitality 
they readily succumb to the slightest ailment, a mild bronchitis or 
fermentative diarrhea being sufficient to terminate their existence. 

In the management of the premature and delicate newly born there 
are four points to be considered — the air the child gets to breathe, the 
nourishment, the maintenance of bodily heat, and the absence of infec- 
tion. It is also to be remembered that we are dealing with an unde- 
veloped body which is not ready for the environment in which it is 
placed. The premature baby should be handled only when necessary, 
and then in the gentlest manner. Bathing is often best omitted for the 
first few weeks, oil being used for cleansing purposes. Because of 
the undeveloped parenchyma of the lungs unusually good fresh air is 
required. Because of the undeveloped heat-centers the body-heat 
of these infants is quickly lost and must be maintained by artificial 
means. The stomach is small and the digestive processes are un- 
developed and weak, so that the nourishment should be of the most 
easily assimilable character. 

Artificial Heat. — The maintenance of heat is of the utmost impor- 
tance. For this purpose incubators and their various modifications 
have been used from time to time. My experience with incubators 
has been unsatisfactory. They may, under careful watching, main- 
tain an even temperature, but all that I have used have been defective 
in supplying fresh air to the child. My incubator babies invariably 
have done badly. The padded crib with the child wrapped in cotton 
and surrounded by hot-water bottles is a safe means of maintaining 
the temperature. A thermometer should rest between the cotton and 
the bed-clothing as a guide to the nurses in the use of the hot-water 
bottles. Ordinarily this should register between 85° and 90°F., 
depending upon the temperature of the child, whose rectal temperature 
should at first be taken frequently. If there is a tendency for his 
temperature to be greatly reduced, — below 95°F., — more external heat 

140 



PREMATURE AND CONGENITALLT WEAK INFANTS 



141 




N 



-1; 

-0' 

.—3 



will be necessary than if the temperature is 97° or 98°F. Various beds 
and devices on the market for the premature are rather fanciful affairs 
but of no greater service than methods perhaps more crude. Means 
and methods complicated in character are to be avoided in treating 
children in the home. 

Room Temperature. — The temperature of the room should be 
maintained at about 80°F., and not under 75°F. 

Fresh Air. — Suitable ventilation may be secured by the window- 
board device (p. 138). 

Absence of Infection. — Only the nurse and rarely the physician 
should be allowed in the room. Infection of any nature is a very 
serious matter. The family generally, and visitors 
always, should be excluded from the presence of the 
premature. 

Feeding of Premature Infants. — Breast-milk for 
premature infants born under twenty-eight weeks is 
almost a necessity, and should always be procured when 
possible for all premature children. The mother, with 
the rarest exception, is unable to supply it, so that a 
wet-nurse should be secured. In selecting a wet-nurse 
for a premature baby it is advisable to take the wet- 
nurse's baby also, as the premature infant may not be 
able to nurse, or if he nurses he will not take all the 
milk. Pumping the breasts of a wet-nurse will almost 
invariably dry them up if her own baby is not with her 
to furnish the necessary stimulation of nursing. Suffi- 
cient milk may be removed by the breast-pump to 
supply the premature infant if he is unable to nurse, and 
the wet-nurse's baby will empt}^ the breast. For pre- 
mature babies who refuse the breast or are unable to 
take a nipple, the Breck feeder (Fig. 9) may be used 
as a means of giving nourishment; or gavage (p. 790) 
may be brought into use. To this I have been obliged 
to resort in several cases. The Breck feeder consists 
of a graduated glass tube, narrowed at one end. Over 
this end is placed a small rubber nipple, the other end 
being closed by a flexible rubber cap. Suction on 
aided and encouraged by pressure on the air-filled cap. 
milk proves too strong, it may be diluted with equal parts of a 6 per 
cent, sugar solution, from one-half to one ounce of the mixture being 
given at first at intervals of from one to one and one-half hours. 
Fourteen to fifteen feedings may be given in the twenty-four hours, the 
amount depending upon the child's digestive abilitj^ If human milk 
is not obtainable, whey made from whole milk may be given, the nutri- 
tional equivalent of which is approximately 1 per cent, fat, 1 per cent, 
proteid, 3.5 per cent, sugar; or one ounce of gravity cream may be given 
with one ounce of milk-sugar and 15 ounces of water, which affords a 
nutritional equivalent of 1 per cent, fat, 5 per cent, sugar, and 0.3 per 




Fig. 9.— The 
Breck feeder. 

the nipple is 
If the breast- 



142 



THE PRACTICE OF PEDIATRICS 



cent, proteid. Evaporated milk (p. 95) is a useful means of feeding 
in these cases. The food strength is increased, the intervals are made 
longer, and the feedings larger, as the patient proves able to assimilate 
the food. 

The premature child requires unusual advantages, and even when 
but one month premature, rarely '^ catches up" during the first year, 
sometimes not for two or three years. 

CEPHALHEMATOMA 

These tumors are usually situated at the site of the caput succedan- 
eum, and are composed of blood. Sometimes pressure of the forceps 
is accountable for their presence, but rarely can any injury be found. 
During a long and tedious labor the pressure on the blood-vessels of the 
scalp is increased, and this is thought to be an active cause in the for- 
mation of these tumors. Blood changes are also cited as a possible 
etiologic factor. The cause cannot be ascribed entirely to pressure 
against the presenting part, as we find cephalhematomata in breech 
as well as in vertex presentations. The hematomata are of three varie- 
ties, as shown by Fig. 10. 

Double cephalhematoma may exist. 




Jeatp 
^Feriosteum 

■Dura matef 

Fig. 10. — Varieties of cephalhematoma: (a) Between scalp and periosteum; (6) 
between periosteum and skull; (c) between skull and dura mater. 

Pathology. — These tumors are generally situated over the parietal 
bones. The scalp may show small hemorrhages and ecchymotic areas. 
The tumor itself is composed of blood. Soon after birth, the blood 
is usually in a fluid state, while in later cases coagulation has taken 
place. The tumor may be infected with pus-forming bacteria and an 
abscess may result. 

Symptoms. — Soon after birth — anywhere from the first to the fifth 
day — a tumor is seen occupying a position generally over the parietal 
bones. It is soft, gradually increases in size for about a week, and then 
diminishes; infrequently a ridge develops around the outer border of 
the tumor, giving the sensation upon pressure of a depressed fracture. 

During the latter stage of the tumor a crackling sensation will be 
elicited on pressure by the fingers. There is no accompanying fever. 
The child shows no annoyance. The tumor does not pulsate. One 
must be careful not to confound this condition with scalp edema, as 
seen in fracture of the skull after severe traumatism. In uncompli- 
cated cases the tumor gradually becomes smaller and smaller, until 
finally, after some five to twelve weeks, it disappears, sometimes leav- 
ing a slightly raised, uneven, bony base. 



ICTERUS NEONATORUM 143 

Diagnosis (Differential). — Encephalocele occurs along the lines of 
sutures or at the fontanels. Pressure may cause convulsions. With 
movements of respiration, the swelling may vary in prominence. 

Hydrocephalus. — The head enlarges as a whole, showing separated 
sutures and large fontanels. 

Caput Succedaneum. — Edematous, does not fluctuate. Disappears 
on second day. 

Depressed Fracture of Skull. — Depression exists and not a tumor. 

Prognosis. — In the uncomplicated cases the prognosis is usually 
good. The prognosis depends upon the amount of injury to the parts 
and the occurrence of any infection. Internal cephalhematoma with 
effusion is invariably fatal. 

Treatment. — These tumors are usually absorbed if let alone. Care 
should be exercised that no injury may happen to them during handhng 
the infant. No dressing is necessary. In infected cases, where the 
formation of an abscess has occurred, incision and drainage are 
indicated. 

ICTERUS NEONATORUM 

The theories relating to icterus neonatorum are most ingenious, but 
as aU, or most all, are based on speculation, they are, as a result, most 
unsatisfactoiy. In fact, only very recently has there been much 
experimental work along this line. 

As Stadelmann stated years ago, ''Without a liver, no icterus," 
so it is true today that theories excluding the liver as a participant are 
valueless. The forms of icterus in which biliary acids are demon- 
strated in the urine must be attributed to the resorption of bile in 
the liver. In icterus neonatorum the presence of biliary acids has 
been clearly demonstrated not only in the urine (Holberstein) , but 
also in the pericardial fluid (Hof meister) . In view of these facts it 
is apparent that the liver must play the all-important part in th^ 
production of icterus because it is certain that the jaundice cannot 
be explained by hyperemia or capillary hemorrhage. The so-called 
hematogenous jaundice deserves more consideration in the light of 
recent experiments. 

Such explanations as that of Franck, assuming a plugging of the 
ductus choledochus by means of mucus and cast-off epithelium, have 
been disproved. Of no further moment is the theory of Birch-Hirsch- 
feld, who assumed an edema of Glisson's capsule; none of these assump- 
tions has been verified by other observers. By anatomic examina- 
tions of the liver Bouchut's hypothesis of a hepatitis, and Epstein's 
theory of a catarrh of all ducts of the liver, have been demolished. 

To the hematogenic factor, which has been strongly supported by 
Hofmeier, Stadelmann, and others, one must give more than a passing 
thought. These authors assumed that, as a result of this countless 
destruction of erythrocytes during the first days after birth, a poly- 
cholia resulted. This supposition of red-cell destruction has been 
refuted, the cause for the apparent destruction being attributed to 



144 THE PRACTICE OF PEDIATRICS 

increase in the blood-plasma. Only recently Heiman (Zeitschr. f. 
Geburtsh. u. Gynak., 1912) has supported the blood-destruction 
theory, stating that an actual destruction of erythrocytes does occur. 
Assuming this later observation to be correct, one can readily see 
how with this destruction there is liberation of hemoglobin, which is 
taken up by the liver and transformed into bile-pigments. It is 
further apparent that when bile is thus produced in excess and is taken 
up rapidly by the liver in large amounts, the bile capillaries are 
overtaxed and the bile cannot be rapidly removed, but is reabsorbed 
into the blood, whereupon choluria develops. If this excessive pro- 
duction of hemoglobin increases over certain limits, the *' threshold 
of the kidney" is reached and the hemoglobin is excreted through the 
kidneys, thus producing a hemoglobinuria (Pearce, Austin, and 
Eisenberg, Jour. Exp. Med., 1912). 

The theory today, which, according to Finkelstein (Lehrbuch d. 
Sauglingkrankh., 1905) finds greatest acceptance, is that of Quincke. 
This author considers a patency of the ductus venosus to be the de- 
ciding factor ; by a persistency of the lumen of this duct the bile passes 
directly from the meconium in the intestine to the portal vein, and, 
circumventing the liver, enters the inferior vena cava, thus producing 
the icterus. In the light of more recent research, however, this duct 
has been found open as late as the fourth week of life; thus if this 
anatomic fact be considered a criterion, we would not be led to believe 
that icterus was produced by the patency of the ductus venosus, for 
if such were the case, icterus would be a phenomenon not of the first 
week, but of the first month of life. 

According to Hess's observation with the duodenal catheter, bile 
is excreted into the intestine rarely during the first twelve hours of life, 
and is variable during the subsequent twenty-four hours, but in every 
one of his cases was profuse in icterus neonatorum. In many of his 
cases of marked jaundice the secretion was so profuse as to overflow 
into the stomach, which was demonstrated by the introduction of the 
stomach-tube. He further states that the cause of this condition is 
not at present definitely proved; however, if one follows the principles 
of the physiology of the secretion of bile, one can assume, what seems 
to be probable, that the icterus is due to an increased amount of 
available hemoglobin; further, that some bile salts are taken up from 
the intestine, resulting in this disintegration of blood-cells and a conse- 
quent increase of bile. Approaching the matter from another view, 
one can readily assume that the diminutive excretory mechanism of 
the liver at this stage is unable to cope with this excess of bile, which 
Hess has demonstrated, and that a congestion of the bile capillaries 
ensues, as is shown by histologic examinations, and icterus results. 

Symptoms. — Probably 75 per cent, of all new-born infants show 
more or less icterus a few days after birth. The degree of jaundice 
varies greatly. In comparatively a small proportion of the cases the 
conjunctiva becomes deeply involved. 

Infants showing marked jaundice may lose in weight as a result 



SCLEREMA 145 

of this condition. The jaundice rarely persists longer than two 
weeks, and such a duration is seen only in the severe cases. In the 
majority of the cases the skin is clear in a week after the onset. The 
urine is usually free from bile-pigment. The stools are normal 
throughout. 

Treatment is not required. 

SCLEREMA 

Sclerema neonatorum (Underwood's disease) is a rare affection of 
early infancy characterized by progressive induration of the skin. 

Etiology. — The condition may be present at birth; the majority 
of the cases develop before the tenth day of life. Nearly all the re- 
ported cases have occurred in premature infants or those weakened 
by preexisting diarrhea or pneumonia. Poor hygienic surroundings 
are included among the possible predisposing causes. 

Pathology. — Parrot described the essential process as a drying-up 
and thickening of the skin, associated with a diminution in the fatty 
elements of the underlying connective tissue. Langer has ascribed 
the condition to a solidification of the fat as a result of low body- 
temperature, a phenomenon more readily possible in the new-born 
infant than in the older subject, because of the peculiar chemical 
composition of infant fat and its corresponding property of solidifying 
at a relatively high temperature (89.6°F.). Other authorities have 
likened the cutaneous changes of sclerema to those occurring in 
myxedema. Mensi* has recently distinguished three types of 
sclerema, depending upon the degree of atrophy in the skin. In 
all the forms atrophy of the subcutaneous connective tissue was the 
chief lesion. Northrup has reported a case in which microscopic 
examination of the skin revealed nothing abnormal. 

Symptoms. — The chief general symptoms comprise progressive 
emaciation and asthenia, subnormal temperature, and failing pulse 
and respiration. The thickening and hardening of the integument 
begin, as a rule, in the lower extremities, and extend upward to the 
trunk and face. The skin assumes a yellowish, waxy hue, and later 
becomes livid and perhaps mottled. It is extremely tense, does not 
pit on pressure, and imparts stiffness to the motions of the joints and 
the play of the muscles of the face. Sucking and swallowing may be 
prevented. The infant usually dies within a few days, but excep- 
tionally may survive the disease. Dr. Lotta Meyers f has recently 
reported a mild case in a female infant, \\ithout the usual subnormal 
temperature, death occurring on the twenty-fifth day. 

Prognosis. — The disease is usually, but not invariably, fatal. 

Diagnosis. — Scleroderma and scleredema, the only conditions re- 
sembling sclerema, may be distinguished by the fact that the first 
has not been noted before the second year (Stel wagon), while sclere- 

* Jour. Cutaneous Diseases, October, 1912. 
t Jour. Cutaneous Diseases, 1909. 
10 



146 THE PRACTICE OF PEDIATRICS 

dema is seldom generalized or accompanied by extreme wasting, and 
does not deprive the skin of its color or elasticity under pressure. 

Treatment. — The only management of possible value consists in 
the maintenance of nutrition and bodily heat. In suitable cases the 
incubator may be used. 

SEPSIS IN THE NEWLY BORN 

The newly born infant is peculiarly susceptible to infections, par- 
ticularly with pyogenic bacteria. During this early period of life the 
normal bodily defenses are weakened. Phagocytosis, which is the 
great protector of the adult, is of little service to the newly born, 
who display little resistance against any bacterial invasion. 

Etiology.— The cause of sepsis in the newly born is the entrance 
of some form of pathogenic bacteria into the body. These bacteria 
are usually of the streptococcus or the staphylococcus groups. The 
pneumococcus, the colon bacillus, and the Bacillus pyocyaneus may 
also cause the condition. These bacteria have been shown to exist 
even in normal breast milk, and they lurk in the air of hospital wards 
and dwellings. The lochia and amniotic fluid of the mother have 
been shown to contain them. The newly born infant is thus sur- 
rounded on all sides by bacteria ready to gain admission to his body. 
The severity of a given case of sepsis is proportionate to the degree of 
virulence of the bacteria at the time of the infection. 

Sources of Infection. — Infection may occur through the mouth, 
which is probably the most frequent port of entry, through the nose, 
the skin, the rectum, the conjunctivae, the digestive tract, the lungs, 
the ears, the urethra, the umbilicus, and, in girls, the vagina. Almost 
any portion of the body may be the seat of the infection. It is rare, 
according to the cases upon which I have made autopsies, to find only 
one organ or structure affected. Usually two or more portions of the 
body are involved in the septic process. 

Parts Most Frequently Involved. — The following parts of the body 
are most frequently involved : 

Umbilicus. — The seat of this infection is usually about, or in the 
substance of, the stump of the umbilical cord. The skin and tissues 
about the umbilicus are red, indurated, and show the usual signs of 
septic infiltration. The blood-vessels of the cord may be the seat of 
inflammation. 

Peritoneum. — Peritonitis may follow the extension of the septic 
process from the umbilical cord to the peritoneum, and under such 
conditions often results fatally. The peritonitis may be local or 
general. 

Joints. — The joint surfaces and membranes may be the seat of 
suppuration, or osteomyelitis may occur. Sometimes the epiphysis 
only is involved, and in other cases the shaft of the bone is affected. 

Skin. — Single or multiple abscesses of the skin and underlying 
cellular structures are also liable to occur. 



SEPSIS IN THE NEWLY BORN 147 

Lungs. — Pneumonia, usually of the bronchial variety, may develop 
as a septic process, with only vague symptoms, such as rapid respira- 
tion and cyanosis, accompanying the fever. 

Intestines. — Diarrhea accompanies nearly all forms of sepsis in the 
newly born. Vomiting may occur. 

Brain. — The meninges are rarely attacked by the septic process, 
and when they are involved, indefinite symptoms of meningitis are 
the result. 

Heart. — A septic pericarditis may occur, but is extremely rare. 
Septic endocarditis is more common. 

Prophylaxis. — This is of the greatest importance in guarding 
against sepsis. The obstetrician's hands and those of the nurse 
should be just as sterile when handling the newly born infant as they 
are in caring for the mother. Asepsis should be stringently observed 
in Hgating the cord. The mother's breasts and nipples should be 
cleansed with boric acid before and after each nursing. 

Prognosis. — Even in its mildest form, septic infection of the newly 
born is very serious. When structures such as the peritoneum, brain, 
pericardium, or lungs are involved, the disease is invariably fatal. 

The red cells are decreased by disintegration, while the leukocytes 
are increased. 

Treatment. — The management resolves itself into relieving the 
system of the infection, which is possible when its seat is in the skin. 
When there is multiple abscess-formation, incision should be made 
and followed by a wet dressing of a saturated solution of boric acid, 
or, if the area is not too large, a 1 : 5000 solution of bichlorid. If the 
site of the infection is at the umbilicus, the suppurating surface should 
be thoroughly cleansed and kept covered with a wet dressing of 1 : 5000 
bichlorid, which should be changed at least every two hours. If there 
is erysipelas, an ointment composed of 30 per cent, ichthyol in vaselin 
affords the best dressing. This should be freshly applied every four 
hours. The septic infant, whether the infection is mild or severe, 
usually nurses very poorly. Often both breast and bottle are re- 
fused. When a sufficient amount of fluid is not taken, plain boiled 
water or sugar- water, 5 per cent., or completely peptonized skimmed 
milk, may be given by gavage. If fluids are not given, the child is 
very apt to develop inanition fever, which, added to the infection, 
makes a serious condition more serious. From two to four ounces of 
a normal salt solution used lukewarm, injected into the descending 
colon through a catheter, will often be retained, with beneficial results. 
It should not be repeated oftener than once in six hours. 

Medication other than smaU doses of alcohol — five drops of brandy, 
well diluted, every hour, if necessary — has been without avail in my 
cases. The prognosis at best is very grave, although cas-es in which 
the vital organs are not involved occasionally recover. 

Illustrative Case. — An unusual instance of infection which ended in recovery- 
occurred in my private practice. The child had no fever, but lost rapidly in weight 
and experienced marked prostration. The skin took on a greenish hue, and we 
were at a loss to discover the cause of the illness. The infection was suspected, but 



148 THE PRACTICE OF PEDIATRICS 

no portal of entry could be found; neither could we find any localized process 
until the nurse discovered that the umbilicus and the surrounding skin were bathed 
in pus. The umbilicus had apparently healed without any indication of local 
trouble. Investigation showed, however, that the infection had entered at this 
site, and, extending along the vein or artery, had become pocketed and formed an 
abscess 1^ inches deep. Enlarging the opening at the umbilicus and establishing 
free drainage were followed by a gradual closure of the abscess cavity and recovery. 

ASPHYXIA NEONATORUM 

Asphyxia neonatorum is a condition of the newly born of grave 
menace to the child's life, and requiring the most active and intelligent 
treatment. 

Etiology. — The asphyxia is due to a subaeration of the blood of the 
fetus or infant. This subaeration may be caused by anything which 
tends to retard the interchange of carbon dioxid and oxygen in the 
fetal circulation, and may take place before or during labor. As a 
result of the interference of the placental interchange of gases, the 
products of metabolism in the fetus stimulate the inactive respiratory 
center. This at first causes respiratory efforts, with the aspiration of 
more or less air, meconium, or amniotic fluid, according to the infant's 
position in the parturient tract, and later, if the subaeration is not 
relieved by the quick extraction of the child, allowing access of air 
for the expansion of the lungs, produces depression of the respiratory 
center. 

The causes operating antepartum include any conditions which 
interfere with the oxidation of the mother's blood, such as heart or 
respiratory disease in the mother, hemorrhage, or eclampsia; any- 
thing which causes a premature separation of the placenta, such as 
placenta prsevia or accidental hemorrhage; and anything which causes 
pressure upon the cord or the child, as the premature rupture of the 
membranes, maternal convulsions, or tetanic contractions of the uterus. 
During labor, likewise, pressure upon the cord from prolapse or mal- 
position, pressure upon the head, with or without meningeal hemor- 
rhage, or separation of the placenta before the delivery of the head, 
as in '' vaginal birth," may cause asphyxia. Prematurity and con- 
genital disability or defects, such as atresia of the pulmonary artery, 
may be causative factors inherent in the child. 

Pathology. — The pathologic changes are due to the venous en- 
gorgement and the aspiration of fluids. The right heart is distended 
with fluid blood or soft clots; the vena cava, the large thoracic veins, 
the sinuses of the dura, and the hepatic vessels are also distended. 
The pulmonary vessels may be distended or not, according to the 
extent and degree of respiratory efforts made. As a result of aspira- 
tion the trachea and bronchi may be quite filled with mucus, meconium, 
blood, and amniotic fluid. The lungs may show areas of atelectasis, 
or may be partially aerated and intensely engorged. The liver is 
dark bluish in color. There may be punctate hemorrhages in various 
parts of the body. 

Symptomatology. — It has been customary to divide the symptoms 
of asphyxia neonatorum into two groups, according to the color of 



ASPHYXIA NEONATORUM 149 

the child and the state of the musculature — asphyxia livida and 
asphyxia pallida. They are essentially the same condition, asphyxia 
pallida being the terminal stage of asphyxia livida, and a case of 
asphyxia pallida (if recovery takes place) passing through the stage 
of asphyxia livida. 

Asphyxia Livida. — The child who is in the condition of asphyxia 
livida presents a characteristic appearance: the skin is blue or livid, 
the mucous membranes are dusky, the sclerotics are congested. The 
pupils are equal and react, and the position of the eyes is normal. The 
respiratory efforts are infrequent and gasping. The heart action is 
rapid and tumultuous, and the heart-sounds are loud. The umbilical 
vessels are engorged and pulsate forcibly. The muscles are every- 
where tense; the reflexes are active; the cutaneous sensibility is pre- 
served, and the skin is warm. The anal sphincter functionates. The 
condition is a sthenic one, and analogous to the convulsive stage of 
ordinary asphyxia. 

A child in this form of asphyxia may recover by the respirations 
becoming more frequent, the color changing to normal hue, the over- 
acting heart quieting down, and a normal condition appearing; or the 
condition may pass by gradual stages into the other form, asphyxia 
pallida. The degree of asphyxia in the beginning may be midway 
between the two types. 

Asphyxia Pallida. — The child with asphyxia pallida is limp and 
pale. The entire musculature is relaxed, the lower jaw and head hang 
down, and the limbs drop. Respiratory efforts are absent altogether 
or so slight as to escape detection. The cord is flabby, the pulsa- 
tion is inappreciable, or can be hardly felt, and the cord, when cut, 
bleeds very little. The heart-sounds are usually faintly heard and 
may be slow or rapid. The sphincter ani is relaxed and allows the 
passage of meconium. The subcutaneous sensibility and reflexes 
are abolished. The temperature is lowered one to three degrees. In 
this form spontaneous recovery almost never takes place. 

Diagnosis. — The diagnosis of asphyxia neonatorum may be made 
intrapartum by detecting the slowing of a previously well-acting fetal 
heart, the passage of meconium in the liquor amnii, the trembling of the 
head in a breech extraction, and the so-called vaginal cry. Post- 
partum, the condition is recognized by the symptoms as detailed. 
Asphyxia neonatorum must occasionally be differentiated from menin- 
geal hemorrhage, which is likewise caused by prolonged labor and 
which often occurs with asphyxia. When the hemorrhage is large, it 
can be. readily recognized by the bulging, tense fontanel and by the 
existence of coma and possibly paralysis. Hemorrhage may affect 
the respiratory center, in which event the two conditions are really 
one. 

Prognosis. — The prognosis without treatment is always bad. In 
cases of asphyxia pallida spontaneous recovery is rare, and even with 
the most active treatment many do not survive. After apparent recov- 
ery death may yet occur from weakness or injuries incidental to the 



150 THE PRACTICE OF PEDIATRICS 

initial asphyxia. Idiocy and feeble-mindedness may often be due to 
the same cause. 

Prophylaxis. — In the treatment of asphyxia, prevention belongs to 
the province of the obstetrician. Everything should be done to avoid 
any of the maternal causative factors, and in the conduct of labor itself 
the aim of the physician should be to deliver the child as quickly as is 
compatible with safety, not hesitating to apply low or medium forceps 
in preference to a long and tedious second stage. 

Treatment. — The active treatment is directed toward maintenance 
of body heat and stimulation of respiration. The child, as soon as 
born, should be wrapped up, and if asphyxia exists, active treatment 
should immediately be instituted. The mouth and throat should be 
wiped free of the mucus, which will almost invariably be found, by 
means of the index-finger well wrapped with absorbent cotton or 
sterile gauze. It may be necessary to suck out the secretions by means 
of a catheter and a glass tube with a bulb on it to prevent the secretions 
from the mouth of the physician or nurse getting into the child^s 
pharynx. This will be especially necessary when, as the result of 
respiratory efforts during the passage of the head through the pelvis, 
much amniotic fluid, mucus, etc., may have been aspirated. It is not 
advisable, however, to attempt much instrumentation of the larynx, 
but to rely on Schultze's method for bringing out aspirated secretions. 
The respiratory center must be stimulated. This may be attempted, 
depending upon the severity of the asphyxia, by tickling the nares, by 
administering the fumes of ammonia, by spanking ("flagellating the 
buttocks," Koplik), by the alternate use of hot (110°F.) and cold 
(60°F.) baths, the child being transferred rapidly from one to the 
other, always ending with the hot one, or by combining with these one 
of the various methods of artificial respiration, of which the sim- 
plest is perhaps the mouth-to-mouth method. Sometimes bleeding of 
the cord will relieve the intense congestion of the right heart and large 
thoracic veins, and allow the heart to restore the circulation and relieve 
the respiratory center. The most commonly used methods of artificial 
respiration are those of Laborde, Dew, and Schultze. 

The Laborde method consists in making rhythmic traction on the 
tongue, from 12 to 14 times a minute, which it is* claimed excites res- 
piration. 

The Dew method consists in grasping the infant by the back of the 
neck with one hand and by the knees with the other. The upper and 
lower portions of the child are then approximated by a flexion of the 
thorax on the abdomen, and the reverse movement, extension, js next 
effected. Alternate flexion and extension are thus practised 15 to 20 
times a minute. 

Schnitzels method is described by him and quoted by Edgar as fol- 
lows: ''The child lying upon its back is grasped by the shoulders, the 
open hand having been slipped beneath the head. The last three fln- 
gers remain extended in contact with the back, while each index-finger 
is inserted into an axilla, the thumbs lying upon and in front of the 



ASPHYXIA NEONATORUM 151 

shoulders. When the child thus held is allowed to hang suspended, 
its entire weight rests upon the two fingers in the arm-pits. It is now 
swung forward and upward, the operator's hands going to the height of 
his own head; the pelvic end of the child rises above its head and falls 
slowly toward the operator by its own weight, flexion occurring in the 
lumbar region. The thumbs in front of the shoulders compress the 
chest, while the hyperflexed lumbar vertebrae and pelvis compress the 
abdomen, and through it the thorax; finally the last three fingers on 
each side compress the thorax laterally. As a result of this manoeuver, 
when properly done, aspirated secretions flow abundantly from the 
mouth. The distended heart also feels the compression which forces 
the blood into the arteries. The child is now s-^^ning back into its origi- 
nal position and supported entirely by the fingers in the axflla. The 
compression of the thumbs and last three fingers is removed. The 
downward swing elevates the sternum and ribs, while gravitation and 
the traction of the intestines depress the diaphragm. It is often pos- 
sible to hear the air rush into the infant's glottis as it reaches the original 
position, although this can occur in a cadaver. The amplification of 
the thorax lowers the intracardiac pressure. The child should be 
swung up and down 10 times for the space of a minute. The effects of 
the manoeuver should be as follows: the heart-beat increases in fre- 
quency, the cadaveric pallor of the skin becomes replaced by a rosy hue, 
and the muscular tonus appears. The child is then placed in a warm 
bath and watched. If the inspirations are superficial, a momentary 
dip in cold water is indicated. If the heart-action becomes poor, the 
child should be swung again. If prolonged swinging becomes neces- 
sary, the root of the tongue should be compressed forward in order to 
raise the epiglottis and permit the removal of secretions with the fin- 
gers. In premature children the thoracic walls are often too soft to 
benefit by the compression of the fingers. In these cases insufflation 
of air should be practised." 

In the cases of asph\Tcia livida, where the reflexes and the cuta- 
neous sensibility are abolished, all attention should be devoted to the 
general stimulation of the child. The cord should be cut at once; it 
will often not bleed at all. The air-passages should be freed from ac- 
cumulated secretions as before. The child should be put into a warm 
bath and artificial respiration attempted by the mouth-to-mouth 
method or Laborde's method. Rectal injection of one to two ounces 
of coffee infusion, or hypodermic injection of 3^^oo grain of strychnin, 
may be given and repeated in half an hour. 

Signs of recovery in asphj^cia pallida are a return of the cutaneous 
sensibility, a reappearance of the reflexes, an increase of the tonicity 
of the muscles, one or more respirations, or a gradually increasing 
cyanosis and venous engorgement approximating the condition of as- 
phyxia livida. Finally, a gradual change to normal hue, with restored 
respiration and relaxation, indicates recovery. 

A strict watch must be kept over the child for several days, for re- 



152 THE PRACTICE OF PEDIATRICS 

lapses are common. Oxygen must be at hand, and all apparatus ready 
for a resumption of the active treatment at any moment. 

DELAYED ASPHYXIA 

Asphyxia may occur after birth in a child who has had an unevent- 
ful delivery and who appears quite normal when born. 

Etiology. — This form of asphyxia is due to some cause interfering 
with the proper continuance of the respiratory function. Develop- 
mental anomalies, such as defects of the nervous system, the heart, 
the diaphragm, the thoracic walls, or the lungs, or the general weakness 
of prematurity, may be the cause. Compression of the trachea by 
enlarged thyroids, and possibly by thymus glands, has been reported. 
Syphilitic pneumonia or bilateral pleuritic effusions or an enlarged liver 
may be the etiologic factors. 

Symptoms. — The clinical symptoms correspond closely to those of 
ordinary asphyxia. The infant makes very feeble respiratory efforts 
or none at all; the heart beats with considerable strength, becoming 
weak as the asphyxia continues and approaches the stage of flaccidity. 

Prognosis. — The prognosis is dependent upon the severity of the 
asphyxia and the removability of the cause. 

Treatment. — Treatment is that of any form of asphyxia, and con- 
sists in stimulating respiration and circulation and the removal of 
the cause. Asphyxia due to prematurity should be treated according 
to the methods advised for caring for premature babies (p. 141). 

ATELECTASIS 

Atelectasis may be present in the newly born who come into the 
world asphyxiated, and it is not infrequently seen when there has been 
a prolonged, difficult delivery. Atelectasis may be the result of weak- 
ness, pure and simple, and is not of unusual occurrence in the pre- 
mature. For some reason there is a failure or inability to dilate the 
air-vesicles. I have seen sudden collapse occur in marantic infants, 
the child dying in a few moments with cyanosis and orthopnea, the 
autopsy proving the diagnosis of atelectasis. The condition may 
be produced also through compression of the lung with exudation in 
pleurisy, or by the obstruction of a bronchus with mucus. The most 
dangerous types are those which are present in the newly born and 
which occur in the weakly during early life. The warning symptoms 
are usually cyanosis and rapid superficial breathing, with or without 
convulsions. 

Treatment. — The management of atelectasis, both in the newly 
born, who come into the world asphyxiated because of prolonged diffi- 
cult delivery, and in those in whom the condition is the result of weak- 
ness, consists in making the child cry lustily. If auscultation over the 
lower lobes posteriorly does not show free vesicular breathing, the 
child should be made to cry every day, either by spanking or by plung- 
ing him first into water at 110°F. and again into cold water at 60°F., 



CONGENITAL ABSENCE OF BILE-DUCTS 153 

our object being to induce vigorous crying and thus dilate the air- 
vesicles. A recent case made satisfactory improvement by receiving 
oxygen inhalations for one minute out of every fifteen, with stimulation 
of various kinds to induce crying. Atelectasis from obstruction of a 
bronchus or from compression is usually readily relieved when the 
source of the trouble is removed. In out-patient work we occasionally 
see marantic young infants in whom there is an involvement of a con- 
siderable area of one of the lower lobes posteriorly without any sign 
whatever of discomfort. The process of resolution in these cases pro- 
gresses from the periphery toward the center and is very slow. The 
condition is probably of much more frequent occurrence than is gen- 
erally supposed, if we are to judge from the autopsy findings in cases 
of young infants, particularly in institutions. 

AMYOTONIA CONGENITA (OPPENHEIM'S DISEASE) 

Amyotonia congenita was described by Oppenheim in 1900. It 
is characterized by a general muscular weakness, observed soon after 
birth, which may be a complete flaccid paralj^sis of the extremities. 
Paralysis of the lower extremities is often complete, but in the upper, 
some movement can as a rule, be obtained. The diaphragm and facial 
muscles escape. The intercostal and neck muscles are often affected. 
The cause is not known. 

Pathology. — In some cases there is degeneration in the anterior 
horns of the spinal cord, but this is not constant. The chief lesions 
are in the muscles which show atrophy and degeneration. 

Symptoms. — The cases show all degrees of severity, from a slight 
weakness which passes entirely unnoticed to a well-marked disability 
which represents a flaccid paralysis, in which the child is perfectly 
helpless. In the latter cases the knee-jerks are absent and the elec- 
trical reactions are ver}' weak. If the intercostals are involved, the 
respirations may be labored and diaphragmatic in character. Choking 
attacks occur from collection of secretions in the pharynx. There is 
no sensory involvement or sphincter disturbances. Mentality is 
normal. 

Prognosis. — The severe forms often end in death from some in- 
tercurrent infection, such as broncho-pneumonia. The mild forms 
may continue for years and show some improvement. 

Treatment. — Massage and electrical treatment may be given but 
they do not offer much hope. 

CONGENITAL ABSENCE OF BILE-DUCTS 

This malformation is of very rare occurrence. The first symptom, 
a rapidly developing jaundice, appears not later than the third day 
after birth. The jaundice increases rapidly, and in a few days is in- 
tense. In a case which I saw at the fifth month the skin was of a deep, 
greenish-yelk) w color, the conjunctiva was deep yellow, and the mucous 



154 THE PRACTICE OF PEDIATRICS 

membranes of the lips and buccal cavity were involved in the discolora- 
tion. In all cases after the passage of the meconium the stools become 
clay-colored and so remain. The urine is of a deep brown color. The 
liver is always enlarged. 

Death usually results from inanition before the third month. In 
one case the child died at the ninth month. In two cases the com- 
mon duct was represented by a fibrous cord ; in another there was an 
entire absence of the common duct. 

Holmes* gives an extensive review of the literature covering over 
100 cases, with 89 diagrammatic representations of the different de- 
formities. These diagrams show a wide range of deformities. 

Diagnosis. — In icterus neonatorum of the familiar type bile is never 
absent from the stools, even though there is a marked degree of jaun- 
dice, and the skin begins to clear in the second week. A continuation 
of the jaundice without abatement after this time is suggestive of con- 
genital obstruction of the ducts, and an examination of the stools de- 
termines the condition. 

UMBILICAL GRANULOMA 

A granuloma at the umbilicus consists of a reddish, secreting mass 
of granulations involving the umbilical stump. It may vary in size 
from the head of a pin to a pea. Granulomata usually occur in cases 
in which the care of the cord has been neglected. In out-patient work 
they are very frequently seen, and occur usually in children who have 
been delivered by midwives. The mother brings the child to the dis- 
pensary with the story that the navel will not heal. 

The granulations are very vascular and bleed readily. 

Treatment. — After thoroughly cleansing the parts, one or more ap- 
plications of a 50 per cent, nitrate of silver solution, followed by the 
free use of an absorbent dusting-powder, soon produces a normal cica- 
trix. A powder of the following composition is recommended: 

I^ Acidi salicylici gr. xv 

Acidi borici gr. xxv 

Pulveris zinci oxidi 

Pulveris amyli aa 5 j 

The powder should be applied very freely at two-hour intervals 
during the day, or at least often enough to keep the wound dry. 

UMBILICAL POLYP 

An umbilical polyp is usually the result of an overgrowth or an 
outgrowth of a neglected granuloma. The mass, which may vary in 
size from a flaxseed to a pea, is reddened, moist, and usually bathed in 
a viscid, mucopurulent secretion. There is often considerable excoria- 
tion of the skin about the umbilical opening. Sometimes the mass is 
so small that it is hidden by the overlapping folds of skin and its pres- 

*Amer. Journal Diseases of Children, vol. xi, No. vi. 



MASTITIS IN THE NEWLY BORN 155 

ence would not be suspected but for the secretion which keeps the 
parts moist. The polyps are very vascular. 

Treatment. — Cutting the pedicle and applying nitrate of silver or 
carbolic acid is not a safe procedure. I have known severe hemorrhage 
to follow such treatment. About twenty five years ago I was obliged to 
sit for three hours by the side of a crying, wriggling child making pressure 
on the cut stump of an umbilical polyp after a colleague had cut the 
pedicle. In no other way could the hemorrhage be controlled. The 
best management in these cases is to ligate the pedicle and allow the 
polyp to wither and drop off. The powder referred to under the head 
of Granuloma should be applied after the ligature is fixed, and reap- 
plied frequently before and after the polyp has dropped off, until the 
wound is cicatrized and dry. 

MASTITIS IN THE NEWLY BORN 

Inflammation of the breasts in the newly born, both in the male 
and in the female, is seen with considerable frequency in hospital prac- 
tice. The mammary glands may be acutely tender and swollen to 
several times their normal size. These glands in young infants should 
not be pressed nor manipulated in any way more than is required for 
cleanliness. Not a few of my out-patient cases of mastitis have been 
due to the attempts of the midwife to express the milk from the breasts. 
The cases are explained by the fact that the opening of the nipple is 
large and the gland readily becomes infected from unwashed hands or 
unclean wearing apparel. 

Treatment. — My cases have usually responded well to the appli- 
cation of ichthyol — 25 per cent, in oxid of zinc, U. S. P. The ointment 
is spread generously upon old linen which has been boiled and dried, 
and is then gently bound upon the inflamed gland. Over this is placed 
oiled silk to protect the clothing, and, over aU, a gauze bandage is ap- 
plied with very light pressure. The dressing should be changed and 
fresh ointment applied every six hours. Wet dressings in the manage- 
ment of this condition in infants are not advised. In five cases the 
mastitis was beyond control when first seen, and suppuration of the 
gland — mammary abscess — followed, requiring incision and drainage, 
with loss of the gland substance. 

Mammary Abscess in Infants. — Mammary abscess is the result of a 
mastitis which has failed to undergo resolution. It occurs as fre- 
quently in males as in females. All my cases but two were seen in in- 
stitutions or in out-patient work. In five the abscess developed under 
my own observation. In a female child, a patient at the New York 
Infant Asylum, both glands were entirely destroyed. As soon as pus is 
discovered the abscess should be incised and drained, with a view to 
saving as much of the gland as possible. Of course, this advice applies 
particularly to a female patient. Wet dressings are not applicable 
in cases of young infants when the parts covering the thorax or abdo- 
men are involved. It is my custom to protect the skin from infection 



156 THE PRACTICE OF PEDIATRICS 

by the use of a 25 per cent, boric-acid ointment in cold cream as a base. 
This is apphed on old linen about the abscess opening. The dressing 
should be changed three times daily. 

TETANUS NEONATORUM 

Tetanus is an acute infectious disease caused by the tetanus bacil- 
lus, an organism having its natural habitat in garden-soil or dung- 
heaps. Its point of entrance into the human body may be a lacerated 
wound, a mere abrasion, or, as is the case in tetanus neonatorum, the 
umbilicus. The local reaction may be very slight or attended by 
suppuration. 

Tetanus is extremely rare in our hospitals and institutions for 
children because of the care exercised in treating the umbilical wound. 
Wherever gross uncleanliness prevails, tetanus neonatorum will be 
found. It is particularly prevalent among savage and half-civilized 
races. 

The Tetanus Bacillus. — The tetanus bacillus is a slender, slightly 
mobile organism, positive to Gram's stain, growing only anaerobically, 
and developing a round spore characteristically placed at one end of 
the rod, giving it a nail or drumstick form. It was described by 
Nicolaier in 1885, and cultivated four years later by Kitasato. 

The bacilli remain localized at the seat of infection, whence their 
toxins are carried along the axis-cylinders of the motor nerves to the 
motor cells of the spinal cord, pons varolii, medulla oblongata, and, to 
a lesser degree, the brain cortex. The localized spasms characteristic 
of the disease are due to the action of the tetanus toxin on the ganglion- 
cells. 

Incubation. — From the second to the ninth day is the usual period 
for the development of the disease, although it may appear as late as 
the fifth or sixth week. The period of incubation of the tetanus bacillus 
in man is possible of wide variation. The disease may appear immedi- 
ately after birth, or be delayed for five or six weeks. Few cases, how- 
ever, develop after the third week of life. 

Pathology. — The lesions found at autopsy in infants dead of tetanus 
neonatorum are few and non-specific in character. Acute omphalitis 
is usually present. The thoracic and abdominal viscera do not show 
any abnormality. The meninges of the brain and spinal cord are con- 
gested, while small hemorrhages into the nerve-substance are frequent. 
These are manifestly the result, and not the cause, of the tetanic 
spasms. 

On microscopic examination degenerative changes in the nerve- 
cells of the gray matter of the spinal cord are noted, but these changes 
are in no way specific. 

Prognosis.- — Few cases recover. Holt reports one recovery. The 
mortality is high. Those writers who have seen much of the disease 
place the mortality at 95 to 98 per cent. 

Symptoms. — The earliest symptom usually observed is difficulty 
in nursing. The child attempts to grasp the nipple and lets go sud- 



HEMORRHAGIC DISEASES OF THE NEWLY BORN 157 

denly and cries. Perhaps the child will give a sudden start and cry as 
though in acute pain, which is doubtless the case. Examination of 
the patient will show well-marked trismus; the jaw is set; the jaw mus- 
cles are tense. Stiffening and relaxation of the muscles occur. As 
the case progresses the muscles of deglutition become involved, and 
swallowing is impossible. The lips are said to pucker in the position 
of whistling. 

The temporary relaxations become shorter ; there is a tonic spasm, 
and, at the slightest irritation, such as the dropping of a pencil or a 
sudden, awkward movement of an attendant, the muscle spasm in- 
creases until a marked permanent opisthotonos results. The tem- 
perature is usually high — 104°F. to 106°F. ; the pulse very rapid — 180 
to 200. Death is usually due to exhaustion. Spasm of the respira- 
tory muscles is probably a factor. 

Treatment. — The treatment consists in the use of antispasmodics — 
among which bromid and chloral are most frequently used. Large 
doses are necessary. 

In Holt's recovery case 8 grains of sodium bromid were given 
every two hours. 

The patient is to be kept very quiet. Food and drugs are adminis- 
tered through a tube. 

Tetanus Antitoxin. — Tetanus antitoxic serum is made by inoculat- 
ing a horse with tetanus toxin formed by the growth in bouillon of the 
tetanus bacillus. Its prophylactic use has been of far greater value 
than its curative effect, and in every case of possible tetanus infection a 
dose of 1500 units of the antitoxin should be injected subcutaneously 
near the wound. In order to do good, after symptoms of tetanus have 
appeared, the antitoxin must be administered as early as possible. The 
New York City Board of Health advises giving the initial dose of 
10,000 units intravenously, and, if possible, also into the spinal canal 
and into the sheath of the nerve of the affected part. These energetic 
measures should be followed by subcutaneous doses of 5000 to 10,000 
units every six to twelve hours for four days. In more severe cases, 
or in those in which symptoms have been present for several days 
before the treatment was begun, the initial dose should be doubled. 
It is also recommended that the wound be treated with a solution of 
iodin and that large amounts of water be given for its diuretic effect, 
since tetanus toxin is eliminated by the kidneys. 

HEMORRHAGIC DISEASES OF THE NEWLY BORN 

In 1861 von Hecker and Buhl described a series of cases, under the 
title of ''Acute Fett-Degeneration der Neugeborenen," that presented 
a somewhat similar picture without evidence of either syphilis or navel 
sepsis. Since that time this condition has been commonly called 
BuhVs disease. In the original article it was noted that most of the 
children were born in asphyxia. These cases showed the typical 
symptoms of the disease, and at autopsy, all the viscera showed mul- 
tiple hemorrhages as large as pin-heads or larger, together with fatty 



158 THE PRACTICE OF PEDIATRICS 

changes that may be extensive. The authors do not attempt to explain 
the etiology, but think that the condition is not due to navel infection 
and that it is not a manifestation of hemophilia because the ratio of 
males to females is not maintained as in hemophilia. In conclusion 
they say: *' It is hardly necessary to state that one here has to do with 
a disturbance of metabolism manifested over the whole body, in which 
the changes in single organs are only a partial expression of the whole 
disease. This disturbance is evidently inborn, acquired in the last 
days before birth." 

In 1879 Winckel tried to establish an entity distinct from the so- 
called Buhl's disease by describing a series of cases that manifested a 
slightly different clinical and pathologic picture. He considered this 
condition distinct from Buhl's disease, chiefly because it seemed to be 
epidemic in character and because the hemorrhages were more, and 
the fatty changes less, prominent than in the disorder described by 
Buhl. Winckel recognized the similarity of this condition to that of 
intoxication by phosphorus, arsenic, and potassium chlorate, and he 
ruled out, by careful histories and by chemical examination* of the 
viscera, any possible participation of these drugs in the etiology of his 
cases. 

In more recent times the Germans, in particular, have come to re- 
gard as Buhl's disease any condition affecting the new-born, that pro- 
duces a severe icterus and fatty infiltration without evidence of infec- 
tion; whereas any similar condition, of which the chief features are 
icterus and hemoglobinuria, has been looked upon as WinckeVs disease. 

These two classifications, however, have failed to suffice for all the 
hemorrhagic icteric conditions of the new-born infant. 

Various other names have sprung into rather general use, and have 
served to complicate the nomenclature by adding terms based solely 
on clinical and morbid anatomic differences. 

Meloena neonatorum is a term that has been applied to conditions 
in which hemorrhage has occurred from the gastro-intestinal tract, 
without necessarily any clinical evidence of hemorrhage elsewhere. 
Since 1829, when Cruveilhier found ulcers in the stomach of an infant 
who presented evidence of a true melena, many others have recorded 
their presence with the result that a gastric or intestinal ulcer is usually 
considered to be the source of the hemorrhage in these conditions. 

Syphilis. — These hemorrhagic conditions have frequently been 
found associated with congenital syphilis. There are hemorrhages, 
cyanosis, edema, icterus, etc., but in many cases evidence of syphilis 
is wanting. Cases of Buhl's disease have been recorded by Fursten- 
burg as occurring spontaneously even in the offspring of domestic 
animals, where presumably the presence of syphilis may be safely 
excluded. 

Bacteria. — The role of bacteria has received the greatest considera- 
tion, for the following reasons: 

1. The close similarity between these conditions and the picture 
produced by navel sepsis. 



HEMORRHAGIC DISEASES OF THE NEWLY BORN 159 

2. The epidemicity of at least one group (Winckers). 

3. The finding of organisms at autopsy. 

4. The experimental production in animals of certain of these 
conditions by inoculation with bacteria. 

The beUef is now almost universally held that many different 
bacteria may produce these diseases, because of the variety of micro- 
organisms that has been found at autopsy (staphylococci, streptococci, 
Gartner's bacillus, pyocyaneus, colon, and various other types). 
The inoculation of animals by many of these organisms has frequently 
been followed by the production of diseases similar to those in human 
beings. In certain cases, at autopsy, lesions indicative of an infectious 
process, as, for example, hyperplasia of intestinal lymphatic tissue, 
have been found, but, on the other hand, such findings are frequently 
absent, and it is very striking that in many cases there seems to be 
very insufficient evidence that infection has played an important role. 

In general one may conclude that there is strong evidence favoring 
the idea that many cases were caused by infections, and, on the 
contrary, insufficient evidence for assuming that all are infections. 

Mechanical Means, — Mechanical factors, such as trauma, thrombo- 
sis, embolism (Landau) , deserve only mention, as they have been found 
only very occasionally (Thomson). 

Heredity. — The possible importance of hereditary influences was 
considered by von Hecker and Buhl when they stated that their 
disease was evidently inborn, and acquired during the last few days 
of pregnancy. The relation of heredity to true hemophilia neonatorum 
needs no further mention. 

There are certain affections of the adult, at present of unknown 
etiology, which, if transmitted to the fetus, might cause their various 
syndromes in the new-born. Reference is made particularly to the 
closely related conditions of acute yellow atrophy, of eclampsia, and 
of certain septicemic conditions. Numerous observations are on 
record describing the pathologic changes in the offspring of eclamptic 
mothers, and it is particularly interesting that in general the ab- 
normal features correspond closely with the icteric and hemorrhagic 
syndromes of the new-born. 

Each report summarizes the pathologic changes as thrombosis and 
parenchymatous degeneration, fatty degeneration or necrosis, espe- 
cially in the liver and kidneys, hemorrhages in the organs, and sub- 
phrenal, subpericardial, and subendocardial extravasations of blood. 

Chemical Agents. — Finally, intoxication by known chemical agents 
occasions symptoms and pathologic changes similar to the disease in 
question. Among this long list of agents may be mentioned phos- 
phorus, arsenic, potassium chlorate, and chloroform. That there are 
many features of these conditions that suggest a common general 
process has already been emphasized by Knopfelmacher. 

Metabolic Changes. — The symptoms and gross changes are sug- 
gestive of poisoning by the above-mentioned agents, but they also 
occur in conditions of obscure etiology, such as acute yellow atrophy, 



160 THE PRACTICE OF PEDIATRICS 

eclampsia, and cyclic vomiting of children. All the chief features 
that characterize this latter group, including certain metabolic phe- 
nomena, such as appearance of lactic acid and sugar in the urine, not 
to mention others, are known to occur also after respiration of rarefied 
air or after asphyxia from any cause, that is to say, from lack of 
oxygen. In phosphorus-poisoning there is a deficiency of available 
oxygen. Chloroform does not belong to this group, producing de- 
ficient oxidation of the tissues; but it would seem, a priori, that there 
was some evidence to suggest the existence of a causal relationship 
between chloroform used at labor and the occurrence of some of 
these various conditions of the new-born. 

Evarts Graham (Chicago) concludes, after a careful experimental 
study, and review of the literature of which the proceeding paragraphs 
are a resume, that the conditions of the new-born characterized by a 
hemorrhagic tendency, icterus, and fatty changes, are probably all 
syndromes which may occur as the result of a number of toxic agents. 
He has produced experimentally the essential features of the diseased 
group by the administration of chloroform to the point of asphyxia. 

Duke believes that the bleeding is due to a deficiency in the 
number of platelets in the blood, and thus absence of thrombus for- 
mation, which is essential in order to produce clotting. In some 
cases the coagulation time is normal, in others, abnormal. 

A considerable number of these cases have come under my personal 
observation. I have repeatedly seen hemorrhages from the newly 
born occur in the internal organs and from various portions of the 
body. A colored infant at the New York Nursery and Child's 
Hospital bled to death in the pericranial tissues without a sign of 
hemorrhage elsewhere. Some cases were due to proved sepsis; in 
others there was no demonstrable lesion of the blood or vascular 
apparatus. It is this latter type that offers the most promising 
results from the human serum treatment referred to below. 

Treatment. — The use of styptics and astringents for controlling 
the hemorrhage is useless. The only measure that has assisted me 
in any way has been the application of pressure to the bleeding parts, 
and this is not possible in many situations. Adrenalin, locally or by 
internal administration, has not been of any appreciable service. 

Illustrative Case. — One of the most important contributions to the literature of 
hemorrhage in the new-born was presented in the Medical Record of May 30, 1909, 
by Dr. Samuel W. Lambert, of New York City. In this case a direct transfusion 
of blood from the father to the child was successful in stopping the hemorrhage 
when the case was almost hopeless. 

Within the past few years the method introduced by Dr. J. E. 
Welch, of New York, has been successfully followed by many phy- 
sicians. It has been successful in five cases coming under my 
observation. 

Welch's methods consist in the injections, under the skin of the 
infant, of human serum which has been obtained under antiseptic 
precautions. The results are usually prompt. The hemorrhage 



HEMORRHAGIC DISEASES OF THE NEWLY BORN 161 

often ceases after the first or second injection. The injections should 
be continued until the hemorrhages cease. 

Welch writes as follows:* 

"As to the dose of serum to be used in any given case, it should be 
said that this depends upon the urgency of the case. One is apt to err 
on the side of too small doses. It is advisable to begin with at least 
1 ounce and repeat three times per day if the infant is bleeding only 
moderately. In severe cases it should be given every two hours, and 
in larger quantities if necessary. It is very important to begin the 
treatment at the first indication of bleeding, however apparently in- 
significant. Slight bleeding of the cord may be accompanied by fatal 
internal hemorrhage if not stopped immediately. 

''The blood is very easily collected. The apparatus I have devised 
consists of a rubber cork through which are two perforations. Through 
one perforation is fitted a U-shaped glass tube, to the outer end of which 
is attached, by means of a piece of rubber tubing, a short aspirating 
needle having a No. 19 caliber. The needle is cotton-plugged into a 
small test-tube, in which it is sterilized. Through the other perfora- 
tion is inserted a fusiform glass tube containing cotton to prevent con- 
taminating the contents of the flask. A small suction tube is placed 
on this latter for drawing the blood into the flask. The needle is in- 
serted into a vein at the elbow and the desired amount of blood with- 
drawn. The blood is allowed to coagulate in a slanting position in the 
flask, and the serum is withdrawn as rapidly as it separates ; it is then 
ready for use. It is advisable to continue the use of the serum for a 
day or two after the bleeding has ceased, in order to insure a control of 
hemorrhage that may be going on in hidden sources." 

During the past year I have successfully treated three cases of 
hemorrhage in the newly born by the use of human blood injections. 
The blood is readily drawn from the basilic vein of the donor and 
injected into the buttocks of the patient. This is the most rapid 
method of treatment as no tests are required for hemolysis and ag- 
glutination. One ounce of blood was used in each case, completely 
controlling the hemorrhage. 

* American Journal Medical Sciences, June, 1910. 
11 



IV, DISEASES OF THE MOUTH AND ESOPHAGUS 
SPRUE (THRUSH; MYCOTIC STOMATITIS) 

The disease makes its appearance in the form of small white masses 
of about the size of a pin-head. The tongue and the inner sides of the 
cheeks are favorite sites for the growth, although in severe cases the 
entire buccal cavity may be studded, as though finely curdled milk had 
been scattered over the surface, and it may extend into the stomach. 
The growth is firmly adherent, and its forcible removal produces slight 
bleeding. Sprue is invariably associated with uncleanliness, and occurs, 
as a rule, in weakly and marasmic nurslings and in the bottle-fed — 
more frequently in the latter. The disease is rarely seen after the sixth 
month. 

Symptoms. — Thrush, soor, or mycotic stomatitis is due to Oidium 
albicans, an organism which stands between the yeasts and the fungi. 
The threads of the mycelium end in egg-shaped conidia which bud 
and form new hyphse. Spores are formed only under favorable 
cultural conditions. Preparations made from the white patches on the 
buccal mucosa show both mycelia and yeast-like conidia. 

An infant with this disease gives evidence of much pain and discom- 
fort while nursing or while feeding from the bottle. Active gastro- 
enteric disturbances, such as vomiting and diarrhea, may be associated 
with sprue, but such association is not the rule. Time and again I have 
seen cases in which there were absolutely no other signs of the disease 
than the characteristic mouth lesions and the patient's refusal of food. 
The average case may easily be cured in a week if treatment is carefully 
carried out. Sprue is not contagious, and if the means of prophylaxis, 
which will be suggested, are used as a part of the daily routine, the dis- 
ease will never appear. 

Treatment. — If the patient is breast-fed, the mother's nipples must 
be washed with a saturated solution of boric acid and moistened with 
alcohol, diluted one-half, which is allowed to evaporate before each 
nursing. If the infant is bottle-fed, both nipple and bottle should be 
boiled after each nursing, and the nipples turned inside out and scrubbed 
with borax water — one ounce of borax to a pint of water. In either 
case the mouth should be washed with a saturated solution of boric 
acid after each feeding. For this purpose a generous amount of ab- 
sorbent cotton loosely wrapped around the clean index-finger of the 
mother or nurse is placed in the cold solution, and then, without expres- 
sion of the water, introduced by the finger into the child's mouth. In 
care of sprue, the application should be brought gently into contact 
with the diseased parts, first on one side and then on the other, and 
finally pressed over the tongue and under the tongue. It is well to 
have the child rest on the side or abdomen so that the fluid which is 

162 



STOMATITIS 163 

pressed out by the manipulation of the cotton against the cheek and 
jaws can readily escape from the mouth. The washing, which really 
amounts to an irrigation, can be done in a few seconds, without the 
slightest danger of abrading the epithelium. In obstinate cases this 
treatment may be supplemented by penciling once a day with 1 per 
cent, solution of formalin. 

Internal medication is of no value except as a means of correcting 
any intestinal derangement that may exist, with a view to improving 
the general condition. If the bottle or breast is refused, spoon-feeding, 
for a few days, may be found necessary, and in any event will hasten 
the cure. If the child is nursed, the mother's milk may be drawn with 
a breast-pump (see p. 35) or pressed out with the fingers and then fed 
by the spoon. The domestic remedy, honey and borax, should not 
be used in treating any of the inflammatory diseases of the mouth in 
children. 

STOMATITIS 

The term stomatitis is applied to an inflammation of the mucous 
membrane of the mouth. Three types are usually described by 
pediatric authors — the catarrhal, the aphthous, and the ulcerative. 
This division is perhaps more the result of the habit of copying from 
former writers, than of clinical observation. Among several thousand 
out-patient, institution, and hospital patients, it has been my privilege 
to treat many cases of stomatitis. 

There are many cases of catarrhal stomatitis which, under treat- 
ment, go no further; other cases, with or without treatment, go on to 
the development of aphthse, or an ulcerative condition. Both con- 
ditions may be combined. Many cases, when they appear for treat- 
ment, have the so-called aphthous spots already developed, but the 
condition described as ''catarrhal stomatitis" also is present. Other 
cases when they come to us show marked ulceration, but never without 
catarrhal symptoms. 

Bacteriology. — Catarrhal, aphthous, and ulcerative stomatitis have 
no specific bacteriologic etiology. 

Etiology. — The cause of the disease is unquestionably an infection, 
and there is no doubt that it is contagious. As to the nature of the 
infection, positively nothing is known. The combined action of 
several varieties of microorganisms is the most plausible explanation. 
I have known stomatitis to go through an entire family of several 
children. Authors are prone to attribute the trouble primarily to 
mechanical irritation, such as careless manipulation during the mouth 
toilet; but the majority of my cases when they applied for treatment 
had never been accustomed to mouth toilets of any kind. The 
giving of overheated food is supposed by some to be a causative 
agent. If this were the case, 75 per cent, of the infants among the 
poorer classes would never be free from the disease. The food of bottle- 
fed children unless carefully watched is almost invariably given too 
hot. The disease, however, is not limited to dispensary patients. I 



164 THE PRACTICE OF PEDIATRICS 

have seen many cases among the well-to-do. Where gross uncleanliness 
is the family habit, the number of cases of stomatitis will, for obvious 
reasons, be greater; there are more bacteria to carry infection. Chil- 
dren whose mouths are carefully cleaned after each feeding do not 
develop stomatitis. To teach that a child's mouth should not be 
washed because an indifferent doctor may fail to instruct the mother 
or nurse as to how it should be done is rank heresy. When errors of 
the mother or nurse occur in performing the various offices for the 
child, it is my observation that, nine times out of ten, the fault is 
due to lack of instruction by the physician. The mouth may be very 
effectually cleansed without injuring the mucous membrane in the 
slightest degree. 

Symptoms. — The first symptom of a stomatitis is a superficial ca- 
tarrhal inflammation of the mucous membrane of the mouth. There 
is a redness and injection of the gums. If '' aphthae" develop, small 
grayish plaques appear on the mucous surface of any portion of the 
buccal cavity. In mild cases there may be but there or four areas. 
In a case of moderate severity the mucous membrane of the gums, the 
hard and soft palate, and the inner side of the cheeks will be studded 
with ulcerated, grayish-white areas, varying in size from a pin-head 
to a split-pea. Occasionally the areas coalesce, forming larger plaques 
of a serpiginous type. 

Ulceration, which ordinarily does not appear until after the catarrhal 
condition has been present for at least three or four days, will first be 
noticed as a faint yellow line at the margin of the gum where it joins 
the teeth. This is the commencement of what Virchow describes as 
''necrobiosis." Ulceration never occurs unless teeth are present. I 
have never known a case to go on to ulceration in a baby fed entirely 
at the breast. Whether the case remains simply catarrhal, or whether 
aphthae or ulceration or both result, certain symptoms are common to 
all. There is a marked increase in the flow of saliva, which, in some 
cases, may be said to stream from the mouth, running down over the 
chin and soiling the clothes. On account of its acid properties it causes 
an irritation of the skin and even an eczema. The mouth is hot and 
painful. Fever is present in a slight degree, both when the condition 
is simply catarrhal and when aphthae are present. There is but little 
prostration and the child appears but slightly indisposed. In cases 
which go on to ulceration, the fever may be very high. I have fre- 
quently seen it 104°F. or over. In one case it reached 107°F. No 
cause except the ulcerative stomatitis could be found for the fever. 
Under properly directed treatment this child recovered in a few days. 

On account of the pain occasioned by drawing on the nipple, nutri- 
tion may be considerably interfered with. The child takes the breast 
or bottle greedily, draws a few times, stops, and begins to cry. If he is 
urged to try again, the behavior is repeated. The pain appears to be 
particularly severe when aphthae are present. The advent of ulcera- 
tion will be indicated by a change in the breath, which becomes dis- 
gustingly foul. The gums are thick, spongy, and bleed easily, and in 



STOMATITIS 165 

some cases overlap the teeth very early in the ulcerative stage. If a 
case has been neglected or improperly treated, which was the history of 
not a few of my dispensary patients, the ulceration is often so ex- 
tensive that the teeth become loose as a result of the destruction of the 
gums, and their removal is necessary. Strong, vigorous children are 
as susceptible to the disease as are the rachitic, the badly fed, or the 
generally delicate. 

Prognosis. — The prognosis is good. All cases recover if seen early 
and if properly treated. Loss of teeth may result in those seen when 
the process is well advanced. 

Treatment. — Mouth-washing. — When the stomatitis is catarrhal or 
aphthous, preventive treatment — the washing of the mouth after each 
feeding with a saturated solution of boric acid in boiled water — is 
also curative. A baby's mouth should be washed as follows: The 
child is placed on its side or on its stomach, the index-finger of the 
mother or nurse being thoroughly wrapped in absorbent cotton. The 
finger is then dipped into the solution, and without expressing the fluid 
it is placed in the child's mouth. By gentle pressure upon the gums 
and cheeks a sufficient amount of the fluid will be expressed to run out 
of the mouth and effectively cleanse it. The washing is assisted by 
the opposition offered by the child to the manipulation of the tongue, 
cheeks, and jaws. 

Drugs. — Internal medication is of no value except indirectly. If 
there is a disordered digestive tract, it should receive attention by diet 
and saline laxatives. Calomel should not be given. Whether the con- 
dition was catarrhal or aphthous, I have never found it necessary to use 
other means than the free mouth-washing. Astringents and caustics 
have never been necessary. The cases usuall}^ recover in from four to 
seven days, under strict attention to cleanliness as regards the feeding 
apparatus or the mother's nipple, together with the free use of the 
boric-acid solution as a mouth-wash. 

Feeding. — The food problem is oftentimes a difficult one to deal 
with, particularly in the case of nurslings, on account of the pain caused 
by drawing on the nipple, the child refusing absolutely to nurse. In 
some cases it may be necessary to draw the milk with a breast-pump, 
and for a day or two feed the baby with a spoon. With the bottle-fed, 
spoon-feeding maj^ also be resorted to. The child will take the nour- 
ishment much better if it is given cool. Small pieces of ice and tea- 
spoonful doses of cold water are taken eagerly. 

Treatment after Ulceration. — With the development of ulceration 
a change in the management is necessary, both as regards a mouth- wash 
and the necessity for internal medication. Among the local measures 
hydrogen peroxid as a mouth- wash, one part of a 3 per cent, solution 
in two parts of water, used after each feeding, has given the best results. 
Such means, however, are rarely necessary if the case is seen early. 
I never employ other than the usual means of cleanliness — the boric- 
acid solution — except in cases that show a considerable destruction 
of tissue. 



166 THE PRACTICE OF PEDIATRICS 

Chlorate of Potash. — In the internal administration of chlorate of 
potash we have what is practically a specific in this disease. Its ad- 
ministration should be commenced as soon as the condition is recog- 
nized. I usually prescribe it in the syrup of raspberry, using one part 
of the syrup to two parts of water. For a child under eighteen months 
of age I order two grains at intervals of two or three hours — not more 
than ten grains in twenty-four hours ; for a child from eighteen months 
to three years of age, two or three grains at the same intervals, not 
more than fifteen grains in twenty-four hours. With the above 
dosage it will be necessary, in the average case, to continue the drug 
from three to five days. Very often, after the improvement is well 
marked, I reduce the dose one-half and continue it for three or four 
days longer. 

Dangers of Chlorate of Potash. — Much has been written concerning 
the danger of the internal use of chlorate of potash in children, particu- 
larly in relation to its effects upon the kidneys. If the use of the drug 
in suitable doses were of special danger in this respect, the free use of 
the chlorate of potash and iron mixture, so extensively prescribed in 
diphtheria in the pre-antitoxin period, would have been universally 
condemned. I have never seen any unpleasant effects from chlorate 
of potash given in doses of 10 to 20 grains daily, and I have used it in 
many hundreds of cases of acute inflammatory conditions of the throat 
and mouth. 

CANCRUM ORIS (NOMA) 

No single microorganism has been proved to be the cause of noma. 
Spirilla and fusiform bacilli have been found (Weaver and Tunnicliff), 
not only in the necrotic tissue, but in the surrounding healthy parts. 
Whether these organisms represent the primary cause of the lesion or 
only secondary invaders is not known. In other instances the Bacillus 
diphtherise has alone been found. The nature of the lesion points to 
the action of a specific infection. 

Symptoms. — The site of the disease is usually the inner side of one 
or both cheeks. The gangrenous process usually begins as a small, 
inflamed, infiltrated area in the mucous membrane opposite the teeth. 
Localized destruction of tissue follows, and this process extends with 
great rapidity until the tissue sloughs away in masses. The parts 
for some distance around the ulcer become hard, infiltrated, and dis- 
colored, presenting an inflamed, edematous look. After two or three 
days a discolored, ecchymosis-like area may be noticed on the outer 
side of the cheek, corresponding in location to the gangrenous process 
within. At this point the ulcer soon perforates. The destruction of 
tissue continues quite symmetrically around the ulcer until the whole 
cheek is destroyed. The gangrenous process not infrequently involves 
the bony structure, causing necrosis of the jaw, with loosening and 
falling out of the teeth. A symptom which will never fail and can 
never be forgotten by one who has seen even one of these cases is the 
almost unbearable stench which emanates from the patient. When 



GEOGRAPHIC TONGUE 167 

the hands or the fingers of the physician or nurse come in contact with 
the gangrenous slough, it is ahnost impossible to remove or neutralize 
the disgusting odor. The disease usually occurs in weakly, marantic 
children, who die, ordinarily, from exhaustion and sepsis within ten 
days or two weeks from the onset of the disease. Hemorrhage is 
rarely a complication. The disease is usually fatal, even under the 
best management. 

Treatment.- — The treatment pursued has consisted in the use of 
free cauterization with nitric acid, chemically pure, and the application 
of disinfectant wet dressings of bichlorid 1 :2000, saturated solution of 
boric acid, or equal parts of alcohol and water. The dilute alcohol is 
apparently more effective in staying the progress of the disease than is 
either the bichlorid or the boric-acid solution. On account of its rapid 
evaporation, the alcohol should be applied on two or three layers of 
lint and covered with rubber tissue. Even then frequent renewals are 
required. Hydrogen dioxid may be used to cleanse the ulcer, both 
before and after perforation. 

FISSURES OF THE LIPS 

Deep cracks and fissures in the lips are of quite frequent occurrence 
among children. Usually the lower lip is involved, and in many of the 
cases there is but one deep fissure and that at about the middle of the 
lower lip. Marasmic, ill-conditioned children are the most frequent 
sufferers. The fissures bleed easily and occasion considerable pain 
during nursing. As a result, less food is taken than the child requires. 

Treatment. — If the fissure is deep, a 50 per cent, solution of nitrate 
of silver should be applied at the commencement of the treatment. 
This is to be followed by frequent applications — three or four times 
daily — of a 25 per cent, solution of ichthyol. Healing is usually 
prompt, requiring but a few days. If the mucous membrane of the 
lip generally is dry and fissured, as in cases of prolonged illness with 
fever, the frequent use of a 5 per cent, boric-acid ointment, made with 
cold-cream as a base, will be of material assistance in controlling the 
condition. 

GEOGRAPHIC TONGUE 

The condition known as a '^ geographic tongue" consists of distinct, 
smooth, reddish patches on the tongue's surface, surrounded by a 
light grayish, narrow, raised border. The smooth surfaces comprising 
the involved areas are devoid of epithelium; the borders are composed 
of hypertrophied papillae which take on a grayish color, making a dis- 
tinct framework for the reddish areas, which are almost always cres- 
centic in shape. This peculiar marking has given rise to the term 
''ringworm of the tongue. " Geographic tongue is seen most frequently 
in children under three years of age, and occurs as often among the 
strong and vigorous as among the delicate and weakly. The condition 
is usually discovered by the mother, who, with much agitation, brings 



168 THE PKACTICE OF PEDIATRICS 

the child to the physician. It does not appear to be due to and is 
usually not associated with any disturbance of the gastro-enteric tract. 
That portion of the tongue which is not involved appears perfectly 
normal. 

Treatment — Treatment of geographic tongue is unnecessary, as the 
condition causes no symptoms and apparently is independent of any 
disease. It is my custom to assure mothers that the condition is of no 
consequence. It usually disappears in a few months. I have known 
a case to last for a year. 

ULCERATIONS AND FISSURES AT THE ANGLE OF THE MOUTH 

Ulcerations and fissures at the angle of the mouth are by no means 
uncommon in delicate and marasmic infants. While ulceration in this 
location is one of the manifestations of congenital syphilis, such ulcers 
are not necessarily syphilitic. The condition, however, is of sufficient 
importance to require treatment, because the affection is so painful 
as to prevent the taking of adequate nourishment. Painting the fissure 
with a 25 per cent, solution of ichthyol every three hours during the 
day will insure prompt healing. 

HARELIP AND CLEFT-PALATE 

Harelip is a vertical cleft in the upper lip resulting from arrested 
embryonic development. This defect may or may not be associated 
with cleft-palate, and varies from a slight indentation in the border of 
the lip to a deep fissure, which may be bilateral, extending into the 
nostril, and complicated by non-union of the palate. In any case 
the deformity will be easily understood if we recall that the normal 
development of the face depends upon the union of the central or 
frontonasal process with the two lateral superior maxillary processes. 
Posteriorly, this union is completed in the median line of the palate, 
and anteriorly, on either side external to the incisors, in the soft 
parts beneath the nostril. 

Etiology. — ^The malformation is more frequent in males than in 
females, and in some instances can be ascribed to heredity. Not in- 
frequently, with cleft-palate, other congenital defects coexist. The 
true cause of the arrest in development is unknown. 

Varieties.^ — Both harelip and cleft-palate may be complete or in- 
complete, unilateral or bilateral. When the harelip is double, cleft- 
palate also almost always exists. Median hare-lip is of exceptional 
occurrence. 

Symptoms. — The character of these deformities is wholly apparent. 
In the simple forms of harelip the disadvantages may be merely cos- 
metic. When there is a cleft in the palate, however, suckling will 
be interfered with, deglutition will be difficult, and if the child goes 
untreated and survives, articulation will be imperfect. 

Treatment. — The treatment of both harelip and cleft-palate is es- 
sentially surgical. The former defect, if uncomplicated, may usually 



THE TEETH 169 

be satisfactorily obliterated by an operation of the Konig or Nelaton 
type. Cleft-palate offers more serious obstacles. Brophy secures an 
approximation of the edges of the cleft by the gradual tightening of 
silver- wire sutures traversing two lead plates, each of which is fitted 
to the lateral portions of the alveolar arch. The operation on the 
soft parts is deferred until the child is fourteen to eighteen months of 
age. When the cleft is small, this procedure may be excluded in favor 
of a more direct method. An operation during the first months of life 
involves considerable risk, but offers better possibilities for good 
development of the nasopharynx than an operation deferred until the 
third or fourth year, after the growth of the teeth. The appropriate 
course to adopt in any case should, therefore, be left to the surgeon. 
In young infants with cleft-palate, spoon-feeding or gavage is fre- 
quently necessary. Good results in some cases are reported to have 
followed the use of a special nipple with a flange on either side, designed 
to bridge over the fissure in the palate. 

THE TEETH 

Twenty teeth comprise the first set. In the well child the first 
tooth usually appears between the sixth and the eighth months; the 
first teeth may, however, in perfectly normal cases, come earlier or 
much later. I have known well, vigorous children who did not get a 
tooth until the thirteenth month. The first teeth are usually the two 
lower central incisors. The four upper incisors and the two lower lateral 
incisors appear normally between the eighth and the tenth months. 
The first four molars appear between the twelfth and the fifteenth 
months; the four canines between the eighteenth and the twenty- 
fourth months; the four posterior molars, which complete the first 
set, between the twenty-fourth and the thirtieth months. This regu- 
larity in the appearance of the teeth is by no means constant, even in 
well children. I have repeatedly seen the upper central incisors cut 
first, and in several instances the upper lateral incisors have appeared 
first. In delayed dentition in rachitis and other forms of malnutrition, 
the teeth are very apt to appear irregularly. In a markedly rachitic 
dispensary patient the molars were the first teeth cut. 

Care of the Teeth. — As soon as the teeth appear they require 
attention. Until the second year is reached the mouth should be 
washed out at least twice a day with a solution of boric acid — J^ 
ounce to a pint of water. This can best be done by means of ab- 
sorbent cotton wound around the tip of a clean index-finger and after- 
ward dipped in the solution, which should be applied with gentle 
friction to the gums and teeth. When a child is two years old, it is 
well to begin the use of a soft tooth-brush and a simple tooth-powder 
composed of the following ingredients: 

I^ Precipitated chalk 5 J 

Bicarbonate of soda 5.1 

Oil of wintergreen q. s. 



170 THE PRACTICE OF PEDIATRICS 

The child should also be instructed as to the proper use of a quill 
toothpick. The teeth of every child over two years of age should be 
examined by a dentist every six months. Cavities discovered in the 
first teeth should be filled with a soft filling. 

The milk teeth are lost between the sixth and the eighth years. 
They should not decay, but fall out or be forced out by the second set. 

The Permanent Teeth. — The permanent set comprises 32 teeth. 
The second dentition begins about the sixth year, and is usually com- 
pleted about the twentieth year, although it may be delayed several 
years. The permanent teeth appear in somewhat the following order: 

First molars sixth year. 

Central incisors sixth to seventh year. 

Lateral incisors seventh to eighth year. 

First bicuspids ninth to tenth year. 

Second bicuspids ninth to tenth year. 

Canines eleventh to twelfth year. 

Second molars thirteenth to fifteenth year. 

Third molars.. . .• after the eighteenth year. 

Dentition. — It is claimed that the eruption of the teeth is a physio- 
logic process, and as such is not productive of harm. In normal well 
babies this is generally the case. There may be a slight fever and rest- 
lessness, with loss of appetite, associated with the eruption of a tooth, 
but the disorder is usually very temporary in character. In delicate 
children, particularly in those who teethe late, as in the rachitic, when 
several teeth are cut at one time, not a little inconvenience may be 
caused by dentition. Even these patients, however, rarely have grave 
digestive disorders. In a large experience with teething infants I 
have known but one in whom convulsions were apparently directly 
dependent upon dentition. The patient was a rachitic, institution 
child who cut his first tooth at the ninth month, and with each of the 
three succeeding teeth, which were cut during the next three months, 
developed convulsions without any other signs of illness. 

Temporary digestive disorders are of very frequent occurrence in this 
type of child during an active dentition. The child may be restless 
and irritable and perhaps have fever of a degree or two. His digestive 
capacity is lessened, and if the usual diet is continued, fermentative 
diarrhea results, which may be, and often is, the starting-point of grave 
intestinal disease. When it is apparent that the child's generally good- 
natured, daily habit of life is being unfavorably influenced by dentition, 
the food should temporarily be reduced, particularly if the weather is 
hot. 

Breast babies may be given water before each nursing so as to re- 
duce the capacity for milk. For the bottle-fed two or three ounces of 
the food mixture may be removed from each bottle, replacing the 
amount with boiled water. 

That cough, respiratory, and skin diseases are immediate results 
of dentition is without foundation. During active dentition, when the 
gums are distended and swollen from pressure, relief will often be 
furnished promptly by rubbing through the prominent points of the 



MALFORMATION OF THE ESOPHAGUS 171 

tooth with a clean towel over the index-finger. Lancing alone may be 
performed, but unless the tooth is well advanced, it is quite possible 
that the gums will reunite over the tooth, forming a cicatrix which will 
make the eruption more difficult than before. If a week or ten days' 
discomfort can be obviated by assisting a tooth through the gum, I 
fail to see any contraindication to such a procedure. 

MALFORMATION OF THE ESOPHAGUS 

Malformation of the esophagus is of infrequent occurrence, and 
when present, is usually accompanied by other congenital deformities. 
In most instances the differentiation of the esophagus from the trachea 
and bronchi, in the metamorphosis of the embryonic foregut, has been 
incomplete. 

The list of possible abnormalities includes the following: 

(a) Total absence of the esophagus. 

(b) Diesophagus, involving partial or complete reduplication of the 
esophagus. 

(c) Esophagotracheal fistula, with or without obliteration of the 
lumen of the esophagus in a portion of its extent. 

(d) Division of the esophagus into upper and lower non-communi- 
cating pouches. 

(e) Congenital stenosis. 
(/) Congenital dilatation. 

The symptoms caused by these conditions depend on the obstacles 
opposed to deglutition. Regurgitation of food and accumulated 
mucus is constant, accompanied by suffocative attacks due to the 
entrance of material into the respiratory tract. Congenital dilatation 
above the diaphragm may produce the symptom of rumination. 

In a large majority of the cases, congenital malformation of the 
esophagus results in death before the tenth day from asphyxia, aspira- 
tion pneumonia, or starvation. 

Gastrostomy offers the only possible means of prolonging the pa- 
tient 's life, till surgery directed at the primary defect can justifiably 
be attempted. 

An autopsy on an infant a few days old referred by me to the 
Babies' Hospital showed that the trachea communicated with the 
esophagus just above the bifurcation. 

The esophagus was normal at its upper portion, dilated lower down, 
and formed a blind diverticulum which ended below the level of the 
tracheal bifurcation. Above the diverticulum the esophagus com- 
municated with the trachea through an opening in its anterior wall. 
Below the diverticulum the esophagus was smaller in caliber than 
normal, but it was pervious and communicated with the stomach. A 
probe could be passed upward through the esophagus into the larynx. 



V. DISEASES OF THE STOMACH, INTESTINES, AND 
PERITONEUM 

THE STOMACH 

Anatomy. — During fetal life the position of the stomach is almost 
vertical, at birth slightly oblique, the obliquity increasing with age. 
At birth the stomach is almost cylindric, and, according to Pfaundler, 
between the time of birth and the seventh month the fundus of the 
stomach increases to fully twice its original length, so that at about 
the end of infancy the stomach lies in a somewhat oblique position, 
passing from behind forward and downward. The diaphragm is pene- 
trated by the esophagus at about the level of the ninth dorsal vertebra, 
while the cardia is about on a level with the tenth. The pylorus, 
though usually situated in the median line, may occasionally be found 
to the right of it. 

Capacity. — The capacity of the infant's stomach is, even up to the 
present day, a subject of more or less speculation, due, no doubt, to 
the fact that during life aspirations are unreliable on account of the 
fact that food passes almost immediately into the duodenum, and 
methods of experiment on the cadaver require an amount of pressure 
(14 to 30 c.c. of water) that does not exist in the normal state 
during life. The stomach undergoes a systolic contraction after 
death, and thus the distention with fluids is artificial. 

The absolute capacity, according to Holt, Rotch, Pfaundler, and 
Fleishmann, varies, depending on the method of examination employed. 
According to Holt's observations based on postmortem examinations 
of 91 infants, the capacity at birth is 13^^ ounces; at three months, 
43-^ ounces; at six months, 6 ounces; at twelve months, 9 ounces. 

Gastric Digestion. — Digestion in the stomach is not so important 
in the infant as in the adult. The function of the infant's stom- 
ach is mainly that of a reservoir, the digestive processes being only 
preliminary. The principal change in the milk, so far as the stomach is 
concerned, occurs in connection with the casein curd, and up to the 
present time it is well established that protein digestion in the stomach 
does not go beyond the stage of peptone formation. Pepsin is found in 
large amounts in the infant's stomach, and, according to some observers, 
occurs as early as the fourth month of fetal life. The reaction of the 
stomach-contents is usually acid inside of fifteen minutes after ingestion 
of food, but free hydrochloric acid is not present till thirty or forty-five 
minutes after, the reason being that hydrochloric acid combines with 
the casein and milk salts. 

The coagulation of milk, which is the first change that it undergoes, 
is brought about through the agency of the rennet ferment. The 
casein coagulum of cow 's and of human milk is essentially different, the 

172 



ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION 173 

former being a firm mass, containing in its meshes the fat of the milk, 
the latter being in fine flocculi, with little of the fat of the milk, and 
readily acted on by the stomach-juices. Due to the infiuence of pepsin 
and hydrochloric acid, solution of the coagulum begins; this occurs 
more rapidly in woman 's milk on account of the lower casein content 
and the small size of the curds. During the first half-hour the fluid 
portion or whey begins to leave the stomach, and at this time a con- 
siderable portion may be found in the intestine, and at the end of an 
hour in a young infant the stomach may often be found empty. In a 
bottle-fed baby the coagula are larger, solution is retarded, and conse- 
quently the food is retained longer. If the milk is boiled, solution is 
more rapid and gastric retention lessened. Some observers believe a 
fat-splitting ferment to be present, but this, if present, plays but a 
small role in digestion. 

Motility. — The duration of digestion varies of necessity with the 
age of the infant and the composition of the food. In general terms 
it may be stated that in breast-fed infants digestion is completed in one 
and one-half to two hours; in artificially fed infants taking raw milk, 
in about one to two hours longer; and in those taking boiled milk, in a 
little less time. 

Cannon has shown that an acid reaction of the contents of the 
pyloric portion causes the pylorus to open, while an acid reaction in the 
duodenum causes it to remain closed. After the coagulation of the 
casein of the milk the whey is readily acidified and passes the pylorus 
first, together with the carbohydrates. As the proteid requires a 
longer time to combine with the acid of the stomach it is some time 
before free acid is present, and the exit of the proteid from the stomach 
is, therefore, delayed. The fatty acids and neutral fats are the last to 
pass the pylorus, because of the longer time required for the fatty acids 
to be neutralized by the duodenal secretions; and the pylorus, there- 
fore, remains closed because of duodenal activity. The opening and 
closing of the pylorus, according to these investigations, depends 
chiefly on the reaction of the gastric contents, which is the most vital 
factor in the motor activity of the stomach. 

ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION 

Not a little confusion exists respecting the differentiation of acute 
gastritis and acute gastric indigestion. Cases of gastric indigestion are 
often diagnosed as gastritis. In fact, acute gastritis in children is a very 
rare condition, while acute gastric indigestion is very frequent. Acute 
gastritis in the young is usually due to the ingestion of corrosive or 
irritant drugs. Food, unsuitable in character or quantity, or food 
which may have undergone chemical or bacterial change, may produce 
pronounced vomiting, usually transient in character. Inflammation 
of the mucous membrane of the stomach may be produced in this 
way, but according to autopsy findings it is most unusual. 

Cases of persistent vomiting which are often diagnosed as gastritis 



174 THE PRACTICE OF PEDIATRICS 

not infrequently prove to be of cerebral or uremic origin, or due to 
some form of intestinal obstruction, or are cases of recurrent vomiting. 

Autopsies on infants dying from acute gastro-enteric diseases, 
such as cholera infantum, rarely show any stomach lesion, although 
there may have been persistent vomiting for two or three days. 

Acute Gastric Indigestion. — Acute gastric indigestion is manifested 
in sudden repeated vomiting, often with fever, always with prostration, 
and with apparent disgust for food. The temperatiu*e may be high — 
104° to 105°F. — or normal throughout. After a few hours there will 
often be evidence of bowel disturbance. The stools will be undigested, 
greenish in color, and contain a moderate amount of mucus. There 
may be moderate abdominal distention. In fact, the symptoms other 
than that of emesis are of a very indifferent character. 

Treatment. — A high enema should always be given as the initial 
treatment in any illness of any nature in which there is acute vomiting 
with an absence of free bowel action. If the vomiting is continued, the 
management of the case, regardless of the exciting cause, is to wash 
out the stomach at least once and to give no food by mouth. If the 
case is of more than twelve hours ' duration in an infant or twenty-four 
hours' in an older child, colon flushings should be carried out to supply 
fluids to the organism (p. 795). A means of much value, both in in- 
fants and in the older children, which I use with great frequency, is 
a solution of bicarbonate of soda, 5 grains in 6 ounces of water, given 
hot in teaspoonful doses at intervals of a very few minutes. 

Diet. — After twelve or twenty-four hours' abstinence from food, 
small quantities of water or some very weak food may be given ten- 
tatively if the child craves it. Whey, skimmed or diluted milk, barley- 
water, weak tea, chicken, or mutton broth, may be tried in teaspoonful 
doses every half hour. Usually cold foods will be retained better than 
those that are heated. If the food or water is rejected, a further stomach 
rest of from eight to twelve hours may be ordered before the 
feeding is resumed. 

Treatment of Protracted Cases. — In the protracted cases, the stom- 
ach should be washed, at least once daily, with a 5 per cent, solution 
of bicarbonate of soda. It is never wise, in the event of vomiting, 
to attempt forced feeding, as nothing will be gained ; in fact the vomit- 
ing may be continued indefinitely, and chronic gastric indigestion 
established, as a result of injudicious attempts at feeding. For the 
persistent vomiting of infants, gavage (p. 790) may also be used. I 
have employed this successfully in a great many cases of persistent 
gastric indigestion with vomiting. A food which is rejected when swal- 
lowed wiU oftentimes be retained when put into the stomach through 
a tube. If nourishment cannot be retained after thirty-six hours, 
when given by the natural method or by gavage, it is best to begin 
feeding by the bowel, using completely peptonized milk, at intervals 
of from six to eight hours, in quantities of from two to four ounces for 
young infants and from six to twelve ounces for children from eight to 
ten years of age. Applications of heat or counterirritation over the 



CHRONIC GASTRIC INDIGESTION (CHRONIC GASTRITIS) 175 

stomach area have been of verj^ httle service. I have treated hundreds 
of these cases of acute indigestion with different forms of medication, 
including calomel, small doses of ipecac, oxalate of cerium, opium, etc., 
and have been far more impressed with their uselessness than with their 
beneficial influence. Drugs oftentimes get credit to which they are not 
entitled for the improvement of the patient. A child has an acute 
attack of indigestion with repeated vomiting. He is, perhaps, given an 
enema, his food is stopped, a certain drug is given in small quantities of 
water, he recovers, and the drug gets the credit. He probably would 
have recovered more quickly without the drug. As a rule, the use of 
drugs, or even a small quantity of water, when given earh^, will prolong 
the attack. 

An enema, the recumbent position, and the withholding of food, 
with nourishment or fluids, such as normal salt solution, by the bowel, 
have given me my best results. When the child craves food and asks 
for water after an abstinence of several hours, feeding maj^ be tried, 
but the fact that he asks for it is by no means a guarantee that what is 
given will be retained. 

Treatment for Persistent Vomiting. — In pronounced, urgent, frequent 
vomiting, morphin hj^podermically may be required. The morphin 
should be guarded by atropin and given in doses of ^o to ^o grain for 
a child one year old, to Ho grain for a child from eight to twelve years 
old. The relation of the dose of morphin to that of the atropin should 
be as 1 is to Ho- Thus, a child who is given 3^o grain morphin should 
have combined with it 3^oo grain atropin; with Ko grain morphin there 
should be given >^oo grain atropin. 

It will rarely be necessary to repeat the morphin more than once, 
two injections being given at intervals of from four to six hours. In all 
cases the usual feedings must gradually be resumed. A trial of differ- 
ent foods will soon show which will best be retained. 

CHRONIC GASTRIC INDIGESTION (CHRONIC GASTRITIS) 

Chronic gastritis is seen most frequently in comparatively young 
infants, and is often associated with, or is a cause of, marasmus and 
malnutrition. 

Symptoms. — Vomiting and regurgitation of food are the predomi- 
nant acute manifestations of the disorder, which, untreated, interferes 
seriously with the nutrition of the patient. The condition is almost 
invariabh^ a result of slight but persistent error in feeding — errors too 
small to make the child violently iU, but sufficient to keep the stomach 
in a constant state of unrest. 

Pathology. — The lesions in these cases are insignificant. There 
may be some superficial, localized congestion at the pyloric end of the 
stomach — there may be destruction of the superficial epithelium and 
infiltration of the mucosa with round-cells. 

Treatment. — The management consists in daily stomach- wash- 
ings, sometimes for a long period, and an adaptation of the food to the 



176 THE PRACTICE OF PEDIATRICS 

child's digestive capacity (p. 62). While there is no one way of 
feeding these cases, a food of greatly reduced strength must always 
be given, particularly when cow 's milk is used. As a rule, these children 
have a low fat capacity — not more than 1.5 per cent, can usually be 
taken. Sugar is also badly borne by many of these infants and must be 
given in reduced strength — from 3 to 4 per cent. only. Usually the 
proteids are fairly well taken care of if the function of the stomach 
is not compromised by too much fat and sugar. In cases of children 
under nine months of age, a wet-nurse may help solve the problem. 
On beginning with the wet-nurse, however, the child should not be al- 
lowed to get over one or two ounces at a nursing, lest the fat in the milk 
continue the trouble. The remainder of the feeding is given by the 
bottle. Granum- water or barley-water No. 1 (see p. 70) may be used 
in quantity sufficient to bring up the amount to the number of ounces 
required. 

Dilatation of the stomach is usually present, and motor inactivity 
necessitates stomach-washing, which may be required for several 
months at gradually decreasing intervals. Details of the treatment, 
which relate largely to feeding, would necessitate a repetition of what 
has been said in the chapters on Malnutrition, Marasmus, and Food 
Adaptation, to which the reader is referred. 

It is to be remembered that in these cases the feeding interval is 
important, regardless of the age. Because of motor inactivity, the 
stomach requires a longer time than the normal to empty its contents 
into the intestine. 

CHRONIC DILATATION OF THE STOMACH IN INFANTS 

In children of any age the stomach capacity may be found greatly 
increased. I have seen the holding capacity increased to two or three 
times the normal. Bottle-fed infants under one year of age furnish 
most of the cases. 

In the absence of pyloric stenosis or pyloric spasm (p. 185) the per- 
sistent feeding of too large quantities of food at frequent intervals is the 
cause. It is not at all infrequent, in cases of malnutrition and athrep- 
sia, to find the patients taking at every feeding from two to three 
ounces above the normal stomach capacity for children of their size 
and weight. 

Symptoms. — Infants with dilated stomachs almost invariably suf- 
fer from indigestion, usually with the vomiting of milk curds and 
mucus, the vomiting generally taking place a considerable time after 
the feeding, and becoming habitual. In marasmus and in the various 
forms of malnutrition the stomach is usually more or less dilated. 

Treatment. — Often, in these cases, the nourishment that has been 
given is of the proper strength, and all that will be required is to reduce 
the quantity allowed and perhaps decrease thefrequency of the feedings. 
The stomach should be washed daily if the child does not respond to 
the simple reduction in the amount of fluid. Particularly is the 



PTOSIS AND DILATATION OF THE STOMACH 177 

stomach to be washed if there is a tendency to fermentation in the 
stomach-contents, evidenced by the presence of gas in the stomach 
and frequent eructations of sour, undigested food and mucus. The 
food should contain a low fat and a moderate amount of sugar. A 
reasonably high proteid may usually be given. Because of the tend- 
ency to fermentation, these cases do badly on the gruel diluents also, 
and these, if they have formed a part of the child's diet are to be dis- 
continued. Small doses of bismuth subcarbonate, 3 grains, bicarbonate 
of soda, 2 grains, benzoate of soda, 1 grain, two hours after each feed- 
ing, have a decidedlj^ beneficial effect. Hydrochloric acid should not 
be given, and pepsin is unnecessary. 

PTOSIS AND DILATATION OF THE STOMACH IN OLDER CHILDREN 

This combination we are finding in a considerable number of 
children who appear for treatment of persistent stomach derangements. 
A dilated stomach, however, may not be ptosed. Our Roentgen ray 
studies of a great many stomachs lead us to believe that Fig. 11 rep- 
resents the normal stomach for a child four years of age. 

Etiology. — The condition in some children is probably carried over 
from infancy, being the outcome of a defective pylorus, and it may re- 
sult from a habitual over-filling of the stomach. Children who have 
the milk habit, who drink large quantities of milk or water with their 
regular meals, are very apt to have dilated and ptosed stomachs. The 
carrying capacity of this organ is not unlimited and the full meal of 
soHd food with a considerable amount of milk or water, produces an 
increase in the weight of the stomach contents, with gradually result- 
ing enlargement and ptosis. 

It will probably be learned that the cases of pyloric stenosis of 
infancy which apparently recover without operation, are sufferers in 
later life from the same condition in a modified form. During the past 
year I have had five patients over two years of age that, according to 
a;-ray demonstrations after a bismuth meal, have shown various degrees 
of pyloric obstruction. 

After the third year the stomach should normally be empty in four 
hours. In one patient the stomach contained residue after ten hours 
and did not begin to empty for two hours. This stomach required 
about twelve hours to empty a bismuth meal. I have had six patients 
in which the stomach contained residue after six hours. 

The Bismuth Meal. — The opaque substance added to the food in 
order to give a contrast in the roentgenogram is bismuth subcarbonate, 
bismuth oxychlorid or barium sulphate, especiallj^ prepared for a:-ray 
work. The opaque substances are usually used in the preparation of 
one part to eight of food, for a child four years of age. 

Symptoms. — The symptoms of the enlarged stomach are quite simi- 
lar but vary in degrees. The appetite is invariably good. The child 
demands a large amount of food and is very unhappy when the volume 
is reduced. They have the drinking habit with their meals abnor- 
mally developed. A symptom with all is the distention of the stomach 
12 



178 



THE PRACTICE OF PEDIATRICS 



with gas and habitual eructation of gas. Stomach pain, sometimes 
paroxysmal after eating, is a very frequent complaint. 

In all but one case there was malnutrition and secondary anemia 
and in all but one there were periodic vomiting attacks at rather in- 




Fig. 11. — Mq,le four years of age. Normal stomach. 



frequent intervals. The sensation of stomach discomfort and food 
craving are very constant symptoms. In one patient, Fig. 13, with 
emptying of the stomach retarded after six hours, there was a persistent 



PTOSIS AND DILATATION OF THE STOMACH 



179 



■urticaria for which the child was brought to me. This child was nine 
years old, the urticaria had first appeared at the age of two years. 




Fig. 12. — Female aged three and one-half months. Entire stomach outline can 
be made out owing to the presence of air. Xo bismuth present. Roentgenogram 
by Dr. L. T. LeWald. 



Fig. 14 represents a case of ptosis in a bo}^ of eleven years, in which 
the stomach failed to empty in six hours. In this child there were 



180 



THE PRACTICE OF PEDIATRICS 



vomiting attacks every two to three months and a great deal of 
stomach pain during the seizure and in the intervals. 

Fig. 15 represents a greatly dilated stomach of a girl two years of 
age. The cardiac end of the stomach is filled with gas. The child 
was brought to me because of frequent stomach pain and abdominal 
discomfort. There was considerable abdominal distention. 




Fig. 13. — Female aged ten years. Ptosis of stomach. Greater curvature 1}-^ inches 
below the level of umbilicus (LeWald). 

Treatment. — The principal point in the treatment is not to over- 
load the stomach at any time. In order to overcome this the meal is 
given with an absence of fluid and the child is made to rest on its back 
or preferably on the right side for an hour after the morning and mid- 
day meal of solid food. Three meals are given daily at not less than 
five-hour intervals. Three hours after the breakfast and mid-day 
meal six to eight ounces of milk or water is given. The evening meal is 



PTOSIS AND DILATATION OF THE STOMACH 



181 



given in bed with eight ounces of fluid. The child is made to he down 
immediately after. Upon awakening the following morning as much 
water is given as the child cares to drink and in one-half to one hour the 
breakfast is served. 

Such a regime carried out for a few months will reduce the size of 
the stomach if there is no pyloric obstruction. 




Fig. 14. — Male aged eleven years. Ptosis of stomach (LeWald). 

In addition to the above, children with ptosis are supplied with an 
Aaron band with a transverse shelf so arranged as to fit under the 
ptosed stomach and furnish support. In those who suffer from accumu- 
lation and eructation of gas 2-grain doses of salicine are given at meal 
time or the following prescription is ordered: 

I^ Magnesia carb gr. xv 

Sodii bicarb gr. xx 

Bismuth sub. carb gr. xxx 

M. ft. chart no XXX div. Sig. One fifteen minutes before meals with water. 



182 



THE PRACTICE OF PEDIATRICS 



In cases of dilatation due to pyloric obstruction operative proce- 
dure of pyloroplasty or gastro-enterostomy may be required. 





DEC 3 1918 

PROftf 




Fig. 15. 



HEMORRHAGE FROM THE STOMACH; VOMITING BLOOD 

With the exception of hemorrhagic disease in the newly born, the vom- 
iting of blood by infants has been due, in my experience, to ulceration of 



ULCERATION OF THE STOMACH 183 

the stomach (p. 183), to purpura fulminans (Henoch's), or to accidental 
causes. In two of my proved cases, extensive ulceration of the 
stomach was found at autopsy. A boy six years of age died on the 
third day with purpura fulminans. There were profuse hemorrhages 
from the stomach, from the mucous surfaces, and under the skin. 
Accidental sources include the swallowing of blood, which may take 
place as the result of a nasal hemorrhage, or from a blow or fall causing 
injury to the nose or mouth, or from the presence of a foreign body in 
one of the nostrils. Injury to the pharynx also may be followed by 
hemorrhage sufficient to cause vomiting if the blood is swallowed. A 
case of hematemesis in a well-nourished breast-fed infant five months 
of age gave me a great deal of anxiety. The vomiting of blood con- 
tinued for several days without the slightest evidence as to its source. 
This occurred two or three times a day, usually shortly after nursing, 
the quantity of blood being especially large after the early morning 
nursing. There were no cracks or fissures in the mother's nipples, nor 
could blood be made to exude from any portion of the nipples on 
reasonably strong pressure. Convinced, nevertheless, that the source 
must be the breast, I applied a breast-pump, making use of as strong 
suction as possible, and obtained milk with a large mixture of blood. 
Evidently there had been a rupture of some of the smaller blood-vessels 
in the gland behind the nipple. At the first nursing the child was very 
hungry and tugged vigorously at the breast, which doubtless explains 
why the early morning vomiting showed the most blood. 

In hematemesis in the newly born the patient should have the ad- 
vantage of the human serum or blood injections (p. 160). 

ULCERATION OF THE STOMACH 

Ulceration of the stomach is usually associated with marked gastric 
disturbance, such as occurs in gastritis and in the different forms of 
malnutrition. 

Notwithstanding a large autopsy experience among infants and 
young children, I have as yet to see a perforating ulcer, tuberculous or 
of other type. In fact, aside from those in the newly born I have seen 
at autopsy only two cases of ulceration. In three other cases the 
diagnosis of ulceration was made because of hematemesis. A child one 
month old repeatedly vomited blood, and eventually bled to death. 
At autopsy about two ounces of coagulated blood were found in the 
stomach. The gastric mucous membrane was the seat of many ulcers, 
varying in size, none exceeding }{q inch in diameter. Another patient, 
three months old, had chronic gastro-enteritis with occasional vomiting 
of blood and died from exhaustion, the autopsy showing multiple small 
ulcers in the mucous membrane of the stomach. That ulcerations, 
even of a mild degree, play any great part in the digestive disorders of 
infants and young children is disproved by the infrequency of the lesion 
at autopsy. 

In treating cases of gastric disorders by stomach-washing it is com- 



184 THE PRACTICE OF PEDIATRICS 

paratively rare to find blood in the water siphoned off. At rare inter- 
vals the water may be tinged with blood, but the washings invariably 
should be continued in spite of this, as I have never known any severe 
hemorrhage to follow. The blood which appears under these condi- 
tions is doubtless from the capillaries of the congested miicous struc- 
ture, which are distended as a result of strain. 

Treatment. — In the event of persistent vomiting of blood of small 
or large amount, which cannot otherwise be accounted for, the walls of 
the stomach are to be regarded as the source of the hemorrhage. 
Under these conditions oral feeding should be discontinued and the 
nutrient enema (p. 83) should be brought into use. Bromid and 
chloral, or stimulants if necessary, may thus be given with the food. 
Suprarenal extract in one-grain doses should be given hourly and 
continued for twelve hours after the vomiting ceases. After thirty- 
six hours water may be given in small amounts; and the usual milk- 
mixture diluted one-half, in small quantities of two or three ounces, 
may also be allowed. The normal diet should not be resumed in 
less than a week, even in the event of an entire absence of vomiting 
during this period. 

DUODENAL ULCER 

Duodenal ulcer is a very unusual disease in infants. In all, one 
hundred cases have been reported. Holt found ninety-one cases 
reported in the literature. To this he adds four cases of his own which 
were observed at the Babies' Hospital. Among 1800 autopsies, 
largely in children under one year, the post-mortem records showed but 
four that had duodenal ulcer. More recently, Veeder* has reported 
five cases. 

Pathology. — The lesions as described by Veeder are as follows: 
the ulcers may be single or multiple, and vary from small areas of 
superficial necrosis to cleanly punched-out ulcers which involve all the 
layers of the intestinal wall and which in a few cases have perforated, 
with a resulting peritonitis. They are found between the pylorus and 
the ampulla and are most commonly situated just beyond the pyloric 
ring. The ulcers are usually located on the posterior wall. 

Age. — The great majority of the cases reported occurred in infants 
under six months of age. The lesion has been found post-mortem, in 
most of the cases not being recognized during life. In Veeder's cases 
proven by autopsy the diagnosis of duodenal ulcer was made ante- 
mortem in one only. 

Symptoms. — The only symptom of value is the presence of blood 
mixed with the stools. When this occurs in a marantic infant, ulcer 
should always be suspected. We would then have to differentiate from 
peptic ulcers, polypus of the lower intestine, fissure of the rectum, 
intussusception, ulcerative colitis, melena neonatorum and diverticula. 
It will be observed that the diagnosis of duodenal ulcer is not a simple 

* Amer. Journal Diseases of Children, vol. vi, pp. 382-393. 



PYLORIC STENOSIS 185 

matter, and it is altogether probable that in the future, diagnosis of 
the disease will continue to be made post-mortem, particularly as in 
some of the cases no hemorrhage occurred at any time. 

THE MANAGEMENT OF VOMITING BABIES 

The baby who habitually vomits or regurgitates his food is one of 
the most troublesome patients with whom we have to deal. 

In such cases the possibility^ of existing pyloric stenosis must be 
excluded. My best results, in feeding these habitual vomiting children, 
have been gained by the use of cereal decoction and -a fat-free milk. 
One ounce of barley-flour to the pint of water is cooked for thirty min- 
utes, and water added to make one pint at the completion of the boihng. 
The child is fed one-third skimmed milk to two-thirds barley-water, or 
one-half skimmed milk to one-half barley-water, depending upon the 
patient's age and condition. Unless the child is very young, the in- 
terval between feedings should be three hours or longer, and he should 
be kept absolutely quiet for one and one-half hours after feeding. The 
handling and tossing about of the vomiting child is one of the best ways 
of keeping up the trouble. If constipation results from such a diet, 
magnesia in sufficient amount may be added to the daily ration. 

It is not to be expected that a patient will grow on the above diet. 
When the vomiting is controlled, the food strength may be advanced 
by the use of whole milk, and later by the addition of milk-sugar. The 
addition of 20 grains of bicarbonate of soda to the day's ration is of 
decided benefit in very troublesome cases. 

By some infants fresh cow's milk will not be tolerated, even in very 
weak dilution. In such instances I have been successful in using an 
evaporated or condensed milk to which cane-sugar has not been added. 
From 1 dram to one-half ounce is added to the amount of barley-water 
given at one feeding. , Such a milk is put up by the Borden Condensed 
Milk Co., and is known on the market as Peerless Brand Evaporated 
Milk. As the preservative, cane-sugar, is not a part of the preparation, 
the contents of a can may be used for only one day. 

Stomach-washing. — Nearly all habitually vomiting children will 
improve more rapidly if they have a stomach-washing every day for a 
week, and every two or three days thereafter, as may be necessary. 
For Vomiting in Rumination see p. 220. 

PYLORIC STENOSIS 

That true pyloric stenosis is a congenital condition is accepted by 
most authors. There are three types of the disease in infants — the 
spasmodic, the hypertrophic, and the combined type. 

Age and Sex Incidence. — In this disease the age is of great impor- 
tance as a diagnostic point. Of 38 patients reported by Still, one be- 
gan to vomit within twenty-four hours after birth and 6 others within 
the first week. Pfaundler found that the first vomiting indicating the 



186 



THE PRACTICE OF PEDIATRICS 



onset of the disease was between the fourth and fourteenth days in 50 
per cent, of the cases; from the second to third week in 25 per cent.; 
and from the third to sixth week in 25 per cent. In my own cases, 39 
in number, the vomiting never appeared later than the sixth week. 
The symptoms may begin a few hours or days after birth, or they may 
not appear until the third or fourth week; occasionally not until the 
second month, and very rarely not until a later date, according to re- 
corded cases. Instances of hypertrophy and stenosis of the pylorus 
coming on in adult life have been frequently recorded, and these niay 
probably be due to a persistence of the condition from early life. 
According to Ibrahim's investigations of 266 cases, the total number of 
cases shows a rapidly ascending curve in the first month and a reduced 
frequency with advancing age. 







IT 


--• 


_,•" 




z 




/ 




z 




_l 




1 




7 




t 




1 




f 




1 








t !. 3 't S < 


^ 7 S 9 lO 



iotal ttutnbeh 
or cases 

260 
Zh-o 
ZZO 

zoo 
i80 
IhO 
/^o 
IZO 
100 

80 
6o 
40 

20 
Weeks of life — 

Fig. 16.— Drawn in accordance with Ibrahim's 266 cases (Pfaundler and Schloss- 

man's System, 1912). 

In the case of a baby five or six months of age, with a history of 
vomiting over a period of three or four weeks, the age alone is a factor 
against pyloric stenosis. In exceedingly rare cases seen in older chil- 
dren vomiting due to stenosis might be confounded with cycUc vomiting. 
Holt has seen one such case. 

Sex. — No great stress is to be laid on sex in the diagnosis of this 
disease. The large number of male patients, however, contrasts re- 
markably with the corresponding small number of females. Out of a 
collection of 42 cases in which this point was noted, 35 were males 
(Still). According to Ibrahim, males are affected about four times as 
often as females. Cases have been met with in the same family (Fre- 
und). This occurred once under my own observation. Someauthori- 



PYLORIC STENOSIS 187 

ties state that when the disease occurs in girl babies, it is usually of a 
mild form. 

Etiology. — Pyloric stenosis is one of the diseases concerning which a 
great amount of theorizing has been done, especially in the early days, 
when few autopsy specimens were at hand. Most of the various sur- 
mises have been discarded, such as the probability of the stomach 
undergoing an agonal contraction, thus producing the thickening 
(Pfaundler). Many new views, however, have been offered, as the 
various names of the disease might suggest. Prominent, and among 
the most universally recognized, theories up to 1897 were those of 
Hirschsprung and John Thomson. According to the former, the dis- 
ease was due to a congenital organic defect, resulting from a primary 
pathologic hypertrophy of the pyloric wall, which constricted the 
lumen. Thomson contended that the essential lesion was not muscular, 
but primarily nervous: *'A functional disorder of the nerves of the 
stomach and pylorus leading to ill-coordinated and therefore antago- 
nistic action of their muscular arrangements." This latter view corre- 
sponds very closely to Still's theory of '^ stomach stuttering." 

There is, to date, no convincing evidence that the spasm is set up 
by erroneous feeding or by hyperacidity. In 7 of 11 cases Peer found 
the total acidity varying from 50 to 105, and free hydrochloric acid from 
to 50. Similar results have been obtained by other observers (Ram- 
sey, Bernheim, Karo, Engel, Freund, Miller, Clark). Miller and Will- 
cox (1901), in a series of carefully conducted investigations, attempted 
to show that pylorospasm may be due to hyperacidity, and that in 
hypertrophic stenosis, spasm, if present, is produced by some other 
cause. In hypertrophic stenosis hyperacidity is very common. 

Of recent years most authorities have regarded the condition as 
primarily spasmodic, and probably due to gastric or duodenal irritation 
or nervous disturbances. According to this theory, the hypertrophy 
is secondary and depends to a large extent upon the degree of spasm. 
The possible existence of a certain amount of antenatal hypertrophy 
may be appreciated when one considers that the pylorus begins to 
form as early as the third month of fetal life. Such hyperplasia has 
actually been found by C. T. Dent in a seven months' fetus. Pyloro- 
spasm has its analogue in certain other spasmodic conditions of the 
circular fibers, such as constipation due to a spastic condition of the 
sphincter ani, and various allied conditions of the larynx and bronchi. 
By some observers, however, the essential condition in pyloric steno- 
sis is regarded as a primary hypertrophy^ with secondary spasm. 

Pathology. — The findings at postmortem are remarkably uniform. 
The alimentary canal below the pylorus is perfectly normal. The 
esophagus is sometimes noticeably dilated, sometimes of normal 
caliber. 

The stomach is usually much dilated, the lower border being fre- 
quently below the umbilicus ; the wall at the cardiac end is as thin as 
normal, but elsewhere much thicker, especially toward the pylorus. 
Occasionally the cardia may assist in the general hypertrophy. The 



188 THE PRACTICE OF PEDIATRICS 

pyloric part of the stomach consists of a rigid, resistant, cartilaginous 
mass of a bulging or nearly cylindric shape. The swelling appears 
like a separately interpolated insertion between the stomach and duo- 
denum. When looked at from the duodenum, the pylorus seems al- 
most closed, the mucous membrane being puckered by the contraction 
of the hypertrophied muscular wall, not unlike that of the os uteri. No 
fibrous stricture is present, and the whole narrowing seems to be due to 
compression by hypertrophied muscle. The tumor enlargement varies 
from 2 to 3 cm. in length, and from 13-^ to 2 cm. in thickness. On 
section, the thickening appears to be due to the hypertrophy of the 
circular fibers, which may be two or three times their normal thickness. 
Finkelstein reports a case in which the thickening was due to an in- 
crease in the longitudinal fibers. The lumen varies in size. In some 
instances it barely admits a fine probe. Walbach, in one case, found 
the lumen 2 cm. in diameter. Occasionally a slight connective-tissue 
increase is found in addition to a slight thickening of the mucosa and 
submucosa. Catarrhal or inflammatory changes are usually absent. 
The test of functional potency by hydrostatic pressure is fallacious, for 
the redundant folds of mucous membrane may act as valves. 

Symptoms. — Vomiting is the only active symptom of the stenosis, 
whether it is spasmodic or due to stricture. The history is usually that 
of an infant, apparently normal at birth, who remains well for two or 
three weeks or more. The child regains the early loss in weight, the 
stools are normal, and there is no suggestion of gastric disturbance. 
Then, without apparent cause, the child, whether breast or bottle fed, 
begins to reject the food. I have never known the vomiting to occur 
before the second week, except in spasmodic cases, in which vomiting 
may occur at birth, or perhaps not until after the eighth week. 

Vomiting.— The vomiting may occur after each feeding. More 
frequently two or three nursings are retained and then a large amount 
is ejected, so that the nurse or mother is impressed with the large 
amount of vomiting, and volunteers the information that two or three 
feedings would be necessary to supply the large amount of food lost. 
In most cases the vomiting is forcible and decidedly explosive in 
character. 

Retention. — The stomach of an infant who takes from three to four 
ounces at a feeding should be empty at the end of three hours. When 
food is retained longer than three hours it means, in a vast majority of 
the cases, an obstruction at the pyloric outlet and is a very valuable 
sign in pyloric stenosis. A retention of one or two ounces is not at 
all unusual and when there is an associated dilatation of the stomach — 
two or more feedings being retained — the retention has been four to 
five ounces. A convenient device for testing the retention is the Hess 
bulb (Fig. 17). By this device all the contained fluid in the stomach 
may be aspirated into the glass bulb and measured. 

Constipation. — With the vomiting is associated constipation. The 
passages, previously full and normal, become very scanty, and are 
passed only upon rectal stimulation. Mucus is usually mixed with the 



PYLORIC STENOSIS 



189 



feces. The degree of constipation depends upon the degree of per- 
manency of the stricture. In the purely spasmodic cases considerable 
fecal material will be passed. A lesser amount will be passed in cases 
of the combined type. 

Loss in Weight. — There is rapid loss in weight, as would be expected. 
I have repeatedly seen such infants reduced to mere skeletons. 

Appetite. — These patients are voraciously hungry, and will take 
everything in the form of liquid food that is offered. Water will 
frequently be taken, as well as milk mixtures or the breast. 

Absence of Other Signs of Illness. — There is no elevation of the tem- 
perature and there are no nervous phenomena. The urine is scanty 




17.— The Hess bulb. 



and of high specific gravity, but shows no evidence of diseased kidneys. 
The child appears ill only on account of the wasting and moderate 
prostration. 

Diagnosis. — In all young infants who develop persistent vomiting 
with constipation, or even persistent vomiting without constipation, 
the possibility of stenosis of the pylorus should be considered. 

The Peristaltic Wave. — This sign consists of a rounded, circum- 
scribed elevation of the abdominal wall, a lump from one to two inches 
in diameter, which forms at the left of the median line, sometimes ap- 
pearing to rise from the margin of the ribs, and passes across the 
epigastrium (maintaining its original size in transit) to the right 



190 THE PRACTICE OF PEDIATRICS 

hypochondrium, where it disappears. In a few seconds the phe- 
nomenon is repeated. Not infrequently, before the first wave disap- 
pears a second will form. I have seen cases in which the elevation 
and depression (see Fig. 18) were sufficient to involve the entire ab- 
dominal wall. The peristaltic wave described occurs in no other 
condition. 

Method of Obtaining the Wave. — The wave may best be demon- 
strated after feeding. The stomach should not be overfull. If the 
usual feeding time is near, two ounces of food or water are given. If 
the child has been recently fed, before giving the food the stomach is 
washed out. The abdomen is then exposed, and usually before the 
child has finished the bottle the peristalsis will appear. Occasionally 
a case is seen in which no peristalsis will be elicited at the first 
examination. 




Fig, 18. — Pyloric stenosis. 

The Tumor. — Palpation of the tumor through the abdominal wall 
is possible in nearly all cases. Considerable practice is required in 
order to be able to locate the tumor. I have not been as successful as 
other writers in demonstrating this conclusive sign. Still was able 
to palpate the pyloric tumor in 41 out of 42 cases. 

Palpation is aided by a partially filled stomach that is in active 
peristalsis. 

Differential Diagnosis Between Hypertrophic Stenosis and Pyloric 
Spasm and Obstruction of the Combined Type. — The palpable pylorus 
may be looked upon as a hypertrophic pylorus. In a pylorus, moreover, 
that has undergone sufficient thickening to be palpable the connective- 
tissue changes are in all probability sufficient to necessitate operation. 
Constipation is always present in stenosis of the hypertrophic form. 
There is dilatation of the stomach, and the vomiting is persistent. In 



PYLORIC STENOSIS 191 

the spasmodic type the vomiting appears to occur periodically — per- 
haps not oftener than once or twice a day. In some cases of simple 
spasm there will be no vomiting for a day or two, and during this time 
the stools will be fairly large. The short cessation will then be fol- 
lowed by a return of the repeated emesis. Cases of this type present 
the best chances for cure without operation. 

In the combined type, in which there is moderate hypertrophy and 
spasm, the stenosis, when the stomach is at rest, is moderate in degree. 
It is possible for a considerable portion of the stomach-contents to pass 
into the intestine if but small quantities of food are given at one time. 
A private case which I expected would recover without operation rep- 
resented this type. Vomiting occurred sometimes once a day — never 
more than twice. The active peristaltic wave was present. The stools 
were fairly large and well digested, from 10 to 15 ounces of food being 
retained daily. Without apparent cause, the child went into collapse 
and died. The autopsy showed a pyloric canal about J^e i^^ch in 
diameter, and revealed moderate thickening and hypertrophy of the 
circular fibers. 

Alfred F. Hess,* of New York, finds the catheter (No. 15 F.) of 
much use in the diagnosis of pyloric stenosis. Under normal conditions 
the catheter readily passes through the pylorus, and bile can be aspir- 
ated. If there is stenosis, the catheter will not pass the pylorus. In 
cases of simple vomiting which may simulate stenosis the ready passage 
of the catheter proves the absence of stenosis. That there may be 
pyloric spasm without hypertrophy, producing typical signs of the 
disease — is represented in a private patient which began vomiting at 
three weeks. There was the peristaltic wave, vomiting several times a 
day, emaciation and constipation. The child was seen by a surgeon 
and operation partially arranged for. The child was bottle-fed and pre- 
paratory to the operation a wet-nurse was solicited in order that the 
post-operative management might be the more secure. The wet-nurse 
was supplied and the baby's stomach was washed daily. In four 
weeks the vomiting had subsided and the child gained two pounds 
two ounces in weight. There was no further trouble with the case. 
Here surely was not a case of organic stenosis. 

Prognosis. — The prognosis is dependent upon many factors. The 
age of the patient and the severe nature of the surgical treatment 
are such that operative procedure will always show a considerable 
mortality. 

The severity of the operation and the tender age of the subject are 
not the only reasons for the high mortality. Many of the patients 
when they come to the surgeon are so emaciated and reduced in vitality 
that operation simply hastens the end. 

In surgical cases in children the surgeon should receive the con- 
sideration of counsel as to when and how long a condition may continue 
and still afford a good surgical risk. 

Cases with Palpable Tumor. — These infants should be given the 
* Amer. Jour. Dis. of Children, vol. iii, p. 133. 



192 THE PRACTICE OF PEDIATRICS 

advantage of immediate operation. Of this there is not the sUghtest 
doubt. It is difficult for me to understand how physicians who have 
examined postmortem the thick, cartilaginous pyloric tissue, with its 
pin-hole lumen, can advise means other than operation. 

The Spasmodic Cases. — There are probably comparatively few 
pyloric cases without involvement of the muscle structure. In such 
cases the prognosis is good, and all should survive without operation. 

In the combined cases of spasm and hypertrophy, which represent the 
largest number of cases, the prognosis is dependent largely upon the 
degree of hypertrophy and the management. Exclusive of operation, 
the management of the spasmodic and combined type is the same. 

Management. — Surgical. — The great majority of cases come to 
operation. In view of the fact that the presence of the tumor is diffi- 
cult to demonstrate, it is not wise for the physician to depend on this 
sign. Frank clinical signs and symptoms in 95 per cent, of the cases 
mean that an organic obstruction exists and that an operation will 
eventually be required. It is best to operate while the child possesses 
a good resistance. The Rammstedt operation offers the best in results. 
This operation consists in making a longitudinal incision from 2 to 3 
cm. in length through the serosa and the hypertrophied circular mus- 
cle fibers of the pylorus down to the thickened mucosa. The duration 
of the operation, according to Downes, is ten to twenty minutes. 
Among thirty-five cases operated by this surgeon by pyloroplasty 
there was a mortality of 23 per cent. 

Postoperative Treatment.— Yomiting after operation rarely causes 
trouble. Regurgitation, which is troublesome, will occur in some 
patients. This may be obviated by bringing the force of gravity into 
use by elevating the head and shoulders of the patient on a high 
pillow. These children need fluid badly, and this may be supplied, 
during the first hours after the operation, by the " Murphy drip." 

Food may be given two hours after the operation. Two to three 
drams of breast milk may be given every two to three hours. The 
quantity is gradually increased so that the child is getting from one- 
half to two ounces every three hours at the end of the third day. If 
breast milk is not obtainable, fresh cow's milk or condensed milk, 
suitably diluted, may be used. 

Palliative measures in the non-operative types: 

First: Diet — breast milk from mother or wet-nurse. If breast milk 
is not available, suitably modified cow's milk given in weak dilution at 
first, and in small amounts, one teaspoonful every half-hour. 

Second: Later the amount of nourishment and the feeding means 
must be determined in each case. If breast milk feeding is not possible, 
then a mixture of cow's milk, low in fat and sugar, or unsweetened 
condensed milk, may be given. 

Third: The stomach should be washed daily with 5 per cent, bicar- 
bonate of soda solution. 

My best results have been obtained with fat-free plain milk or 
evaporated (unsweetened condensed) milk. The milk is diluted with a 



ACUTE GASTRO-ENTERIC INTOXICATION 193 

gruel, which adds to the carbohydrate content. In any case of pyloric 
obstruction the passage of fluids from the stomach is delayed. The 
presence of fat and sugar gives rise to irritating chemical changes in the 
contents of an organ already inclined to eject its contents. 

Catheter Feeding, — Feeding by means of the catheter No. 15 (French) 
passed into the duodenum has been a useful means, according to 
Hess, of supplying nourishment to persistent vomiting cases. 

Medication. — I am further very much inclined to keep out of the 
stomach everything except food and a weak bicarbonate of soda so- 
lution. Bicarbonate of soda, 10 to 20 grains to the pint, is invariably 
added to either the food or the water. I do not look with favor upon 
the preparations of opium or the bromids, and think that little is to 
be expected from them. In some cases they increase the vomiting. 
If a sedative is to be administered by the stomach, paregoric, 5 to 10 
drops, well diluted, answers best. 

Later Operations. — When the vomiting continues in spite of treat- 
ment, and the child shows progressive loss in weight and strength, it is 
safe to assume that a considerable degree of hypertrophic stenosis exists 
and operation should not be delayed. Temporizing is safe only when 
there is no pronounced loss in weight. 

Rectal Medication. — For sedative effects six grains of bromid of 
sodium with one grain of chloral in one ounce of mucilage of acacia may 
be passed into the descending colon through a No. 14 American cathe- 
ter. In order to place the solution in the colon, the catheter should be 
introduced eight inches. The colonic medication will be useful for a 
day or two only, as the parts soon become intolerant, and such medi- 
cation is no longer retained. I never employ this method oftener 
than twice in twenty-four hours. 

Local Applications to the Stomach. — ^Local treatment is of little or no 
value. I have yet to see any improvement follow the use of stupes, 
compresses, or irritant applications. 

ACUTE GASTRO-ENTERIC INTOXICATION 

In the consideration of this subject we deal with a most important 
portion of the child's anatomy, parts that differ in their location in the 
body, in their anatomic structure, and in function. The gastro-intes- 
tinal tract is exposed, of necessity, to influences frorn without which 
may exert decided effects upon the physiologic processes of its different 
parts. It is obvious that there may be lesions in any part of its struc- 
ture, and that such lesions may cause a derangement of function, if not 
actual disease, by transference (bacterial) to other parts of the tract. 
Thus there may be lesions, single or multiple, in various portions of the 
gastro-intestinal tract. There may be a simple gastritis, or an ileitis 
or colitis singly or in combination, entirely independent of pathologic 
conditions of the other portions of the tract. The function of the gas- 
tro-intestinal tract is the preparation of food-substances for the use of 
the organism. These food-substances are perishable in character and 
13 



194 THE PRACTICE OF PEDIATRICS 

susceptible to bacterial influences and chemical change. Obviously, 
this long tube, adapted for absorption and of an anatomic and physio- 
logic construction of most intricate and sensitive nature, offers ready 
fields for bacterial invasion and chemical change, and consequently is 
subjected to constant insult by toxic agents resulting from bacterial 
and chemical processes. 

For the past two hundred years investigators have attempted a 
classification of the acute gastro-intestinal disorders, and while much 
progress has been made in framing a classification sufficient for bedside 
and teaching purposes, let no one imagine that the last word has been 
said. With an increase in knowledge of the subject, old theories and 
concepts will be disproved and new ones evolved which may share the 
fate of their predecessors. It is not wise to be carried away by the 
theories of our time concerning a subject the etiology of which is based 
upon so many factors, not the least important of which is that of 
physiological chemistry, a subject of which we can boast but little abso- 
lute knowledge. 

Until we possess demonstrable facts, it is best, in teaching, not to go 
into vague chemical and metabolic theories which no one under- 
stands. 

Types. — The gastro-intestinal disorders, exclusive of the simple 
digestive derangements already mentioned, may be divided clinically 
into two types; first, those in which there is an acute, severe, gastro- 
enteric intoxication without demonstrable lesions and with characteris- 
tic symptoms; second, acute ileocolitis with moderate early intoxica- 
tion, characteristic symptoms, and demonstrable lesions. Clinically, 
and probably etiologically, there are two forms of acute gastro-enteric 
intoxication. 

A. Cholera infantum. 

B. Acute enteric intoxication. 

While there are various degrees of severity of the acute gastro- 
enteric disorders, certain features are common to all: 

(a) They are most prevalent during the hot months. 

(b) Selection as to the type of child attacked. The rachitic and 
those suffering from various forms of malnutrition are the most sus- 
ceptible subjects. 

(c) Nearly all the patients are bottle-fed. 

(d) The illness is rarely primary. A field has been prepared for 
the toxic process by mild, but perhaps persistent, digestive derange- 
ments. 

Gastroenteric Intoxication 

This form of intoxication, while acute in character, is rarely of pri- 
mary origin. It is usually preceded by disordered gastro-enteric 
digestion. 

The onset is sudden, with pronounced prostration, persistent vomit- 
ing, retching, and the passage of large, watery stools of greenish color. 
The pulse is soft and rapid. 



ACUTE GASTRO-ENTERIC INTOXICATION 195 

In a few hours the prostration becomes extreme, the respiration 
quick and shallow, the eyes sunken, and the skin dry and ashen in color. 
The extremities are cold; thirst is intense. The fontanel is depressed. 
The anus becomes relaxed, and often there is a constant slight discharge 
of the intestinal contents. 

The temperature is variable and inconstant — it may be high, 105°F. 
to 106°F., or it may never arise above the normal. The lower tem- 
perature cases with repeated vomiting and profuse diarrhea are the 
most hopeless. The system is so overwhelmed by the poisoning that 
a reaction is impossible. 

As the disease progresses toward a fatal termination the patient 
develops stupor and occasionally convulsions. Coma rapidly ensues, 
and death from a virulent poisoning process is the outcome. 

I have seen infants die in twelve hours from the onset of the symp- 
toms. The loss of weight is most rapid. In twenty hours a nine- 
months-old baby lost two pounds. The loss of a pound or more in 
twenty-four hours is not at all unusual. At the Nursery and Child's 
Hospital a child fifteen months of age was taken acutely ill with vomit- 
ing and diarrhea at 11 o'clock in the morning. The child was seen by 
the House Physician, and suitable management was instituted. On 
my rounds at 4 o'clock we discovered the child moribund in spite of 
active treatment, and death took place six hours later. Thirty-one 
children in this institution were poisoned by a can of stale milk left by 
a dealer who was short of a sufficient fresh supply. Thirteen deaths 
in children under eighteen months were traceable to this can of milk. 

Not all cases are as severe as the foregoing descriptions represent. 
There are cases in which there is a sharp rise in temperature, — 105° to 
106°F., — with active vomiting and profuse watery stools. The fever 
soon subsides. The stomach is washed, milk is withheld, boiled water, 
weak barley-water, or rice-water No. 1 (see formula, p. 70) is given, 
and the child is well in a few days. In the more severe cases that re- 
cover several weeks elapse before the child regains his usual vigor. 

The Urine. — The urine contains albumin, and usually a few hyaline 
and epithelial casts — findings that are common in all severe acute toxic 
processes, and have no immediate or remote bearing upon the illness. 
While I was resident physican at the N. Y. Infant Asylum in 1890, the 
examination of the urine in a series of 12 cases of acute gastro-intestinal 
intoxication showed the presence of lactose. 

Acidosis. — Infants ill with intestinal intoxication not infrequently 
develop a severe acidosis. In such cases the prostration is extreme. 
There is rapid breathing — evidence of air-hunger without cyanosis or 
respiratory obstruction, and with the chest signs negative. Coma 
early supervenes and the outcome is usually fatal. 

Pathology. — The postmortem findings are negligible. The stom- 
ach and intestines present a very pale, washed-out appearance. The 
intestine usually contains a mucoid, yellowish substance entirely free 
from fecal odor. The brain may show a cerebral anemia; more often 
there is moderate edema of the meninges — the so-called wet-brain. 



196 THE PRACTICE OF PEDIATRICS 

Treatment. — The management of the case depends entirely upon 
the nature and urgency of the symptoms. In the acute choleraic 
cases, with repeated vomiting, severe toxemia, retching, and profuse 
watery stools, stomach-washing and bowel irrigations are useless pro- 
cedures. We must support the patient and aid him to bear the poison 
with which he has to contend. If the temperature is high and the 
skin dry and hot, a cool pack to the trunk, at 85° to 90°F., subsequently 
moistened with water at this temperature every half-hour, will often 
control the pyrexia. If the feet are cold, hot-water bottles should be 
brought into use. If the temperature is below normal and the periph- 
eral circulation poor, as indicated by a leaden hue of the skin, a hot- 
water bath at 108°F. for five minutes will always be of service. The 
bath may be repeated at half-hour intervals. In addition, the imme- 
diate treatment calls for hypodermic stimulation and sedatives. The 
administration by mouth of food or stimulants should not be attempted. 
Tincture of strophanthus and brandy, hypodermatically, have served 
me well in these cases. Twenty drops of brandy with one drop of 
the tincture of strophanthus may be given at intervals of one, two, 
three, or four hours, depending upon the urgency of the case. A com- 
bination of morphin and atropin may be used in cases with persistent 
vomiting, with a view to controlling the attempts at vomiting which 
exhaust the patient, and also to diminish the continuous loss of the 
fluids of the body, from the repeated large, watery stools. Obviously, 
morphin should not be given unless this condition exists. For a child 
one year of age 3^o grain of morphin may be given with J^qo grain 
atropin, and repeated as required, not oftener than once in two hours. 
After the first year y^Q grain of morphin may be given as an initial 
dose. Beneficial effects from the morphin will be noted in a diminution 
in the number of stools and the frequency of the vomiting. In milder 
cases of infection, in which the vomiting and defecation are less fre- 
quent, a different course is to be pursued. In these cases there should 
be abstinence from food, boiled water being given if the child can retain 
it. If vomiting persists, the water should be discontinued. The 
stomach should be washed at least once daily and the colon irrigated. 
If the irrigation brings away mucus and fecal matter, it should be re- 
peated at intervals of from eight to twelve hours. The child should 
never be disturbed for this purpose if the intestine continues to empty 
itself at frequent intervals. A reduction in the temperature, cessation 
of the vomiting, and a diminution in the number, and improvement in 
the character, of the stools, tell us whether or not the case is doing well 
and determine the further treatment, after the initial dose of castor oil 
or calomel has been given. As a rule, the milder type of case does 
better when calomel is used. If there is a tendency to vomit, the oil 
will rarely be retained, regardless of how it is given. From J-f 5 to 
J^o grain of calomel may be given at fifteen-minute intervals until one 
grain is given. While slower in its action, it is ultimately of more bene- 
fit than the oil, which is rejected. 

Milk Substitutes. — When the vomiting has subsided, teaspoonful 



ACUTE GASTRO-ENTERIC INTOXICATION 197 

doses of plain water, bicarbonate of soda solution, barley-water, 
granum-water, or rice-water, should be given at fifteen-minute or half- 
hour intervals, and the amount should be increased in quantity and 
be given less frequently as the case improves. It is well, in using milk 
substitutes, such as cereal waters, to use alternately, for the sake of 
variety, three or four different preparations. The child will not so soon 
tire of the milk substitute as when but one is given, and will thus take 
more food. It is extremely rare that the substitutes barley, rice, or 
granum will not be taken if used in this way, particularly if they are 
made more palatable by the addition of salt and sugar or saccharin. 
In cases showing signs of acidosis, bicarbonate of soda should be given 
at once, 10 grains every hour if possible, until the patient receives at 
least 120 grains in twenty-four hours. It is to these urgent cases that 
the soda should be given intravenously or by hypodermoclysis (p. 796). 

Termination. — The termination of acute gastro-intestinal intoxica- 
tion is in death, prompt recovery, or in the development of ileocolitis. 
The transition to an ileocolitis in some cases is so sudden that its exist- 
ence from the onset is often assumed. That such is not the case is 
proved by a large autopsy experience in hospital and institution work, 
with cases dying in a day or two from toxemia, in which no intestinal 
lesions of consequence were found. The continuation of fever and 
diarrhea, with loose green mucous stools, means that an ileocolitis has 
developed as a result of the toxic agents in the intestine. 

Drugs. — Unusual care must be exercised in the use of astringent 
drugs in the cases we are discussing. I refer particularly to cases that 
are mild or moderately severe. It is to be remembered that it is in the 
intestinal contents that the trouble exists, and not in the intestinal 
structure, and that the, diarrhea is a conservative attempt on the part 
of nature to protect the intestinal structure. Our first efforts, there- 
fore, should not be directed toward stopping the diarrhea, but toward 
assisting in the elimination of the intestinal contents productive of the 
illness. The indisjcriminate use of opium and astringents may do ir- 
reparable damage in a very short time through a locking up of the in- 
testine, which may be followed by a sudden rise in temperature, convul- 
sions, coma, and death. Opium is a most useful drug for the treatment 
of diarrhea in children, but must be used with caution. When there is 
tenesmus, with frequent large, watery stools, opium may be given in 
small doses sufficient to control the number and character of the stools, 
with a view to prevention of an excessive loss of fluids from the body. 
This drug should never be given when there are only four or five free 
evacuations in twenty-four hours, associated with more or less fever, as 
in these cases this number is required to maintain proper drainage. 
The opium should further be given independently of other medication, 
so that its use may be stopped when the excessive number of stools 
ceases, or in the event of a rise in temperature after it has been given. 
It would not be desirable, perhaps, to discontinue the bismuth or other 
drugs which may have formed a part of the prescription. In using 
opium I prefer Dover's powder, 3^ to % grain, at intervals of two or 



198 THE PRACTICE OF PEDIATRICS 

three hours, for a child from six to eighteen months of age. Bismuth 
subnitrate in not less than 10-grain doses at two-hour intervals has given 
most satisfactory results. In order to be of service it must produce 
black stools. In other words, if the bismuth is not converted into the 
sulphid in the intestine, it apparently is of no service; if it passes 
through the bowel unchanged, no favorable influence will be exerted on 
the intestinal contents. This occurs in a small percentage of cases. In 
such an event the necessary amount of sulphur may be supplied by the 
use of precipitated sulphur, one grain being added to each dose of the 
bismuth. A convenient and agreeable way of giving the bismuth is 
the following: 

I^ Bismuthi subnitratis 5 v 

Syrupi rhei aromatici 3iij 

Aquae q. s. ad § iv 

M. Sig. — One teaspoonful every two hours. 

If sulphur is necessary, a one-grain powder may be added to each dose of 
the bismuth mixture at the time of its administration. In the same 
way Dover's powder, if opium is indicated, may be dropped into the 
bismuth mixture. The bismuth is continued in the large doses until 
the child is ready for milk, when the dose is diminished one-half and 
continued until full milk-feeding is permissible, or until constipation 
demands its discontinuance. In using the bismuth in the large doses 
advised it is necessary that the chemically pure drug be obtained. 
If free nitric acid or arsenic is present, as is the case in some of the 
commercial bismuth on the market, vomiting may result, or symptoms 
of arsenical poisoning may develop. Irrigation of the colon (p. 793) 
may be used when there is a tendency to bowel inactivity with high 
temperature. If there are loose watery passages, irrigation is not 
called for. 

Hypodermoclysis. — The injection of warm normal salt solution into 
the cellular structures of the body is frequently advocated by pediatric 
writers for the very urgent cases in which there is extreme prostration 
and rapid loss in weight due to the persistent watery discharges. I 
have employed this treatment in a great many cases and have never 
demonstrated that it is a measure of any great utility. In the cases 
where the addition of the fluid is most needed, it will not be absorbed 
because of the lowered vitality of the patient. Those whose tissues are 
able to take up the salt solution appear to do well without it. 

Diet. — A difficult problem of no little importance is the nutrition of 
the patient after the acute symptoms have subsided. When the tem- 
perature has been normal for two or three days, and the character of the 
stools improves to such a degree that freer feeding than carbohydrate 
decoctions is to be thought of, unusual care is necessary in order to 
avoid a reinfection. 

Skimmed Milk. — It must, of course, be our effort to resume milk- 
feeding as early as possible, but in resuming milk the amount given 
must be increased very gradually — at first only one-quarter to one-half 
ounce of skimmed milk being given in every second feeding of the cereal 



ACUTE GASTRO-ENTERIC INTOXICATION 199 

gruel. In not a few cases even these small amounts will result in a rise 
of temperature and a return of the diarrhea. There are always patho- 
genic bacteria remaining in the intestinal tract after an illness of this 
nature, which, under the influence of such a favorable culture-medium 
as milk, take on renewed activity. The w^hole illness may, therefore, 
be repeated, perhaps with greater severit}^ than the original one, if the 
milk-feeding is persisted in. I have repeatedly seen in consultation 
infants who were having what w^as called a relapse. What they did 
have was a reinfection, with all the symptoms as severe as, or more 
severe than, those of the first infection, because of a lack of appreciation 
of the necessity of great care in resuming milk. To avoid mistakes in 
feeding at this time, as well as early in the disease, all directions should 
be carefully written. Nurses and mothers who think the physician 
is overcautious and pity the hungry child are very apt to forget oral 
instructions and give more milk than is ordered. If the small amount 
of milk agrees, it may gradually be increased b}^ the addition of one- 
half ounce to each feeding ever}^ two or three dsLVS. Rarely, however, 
will it be possible or wise to attempt to give, for the remainder of the 
summer, as strong a food as was taken before the illness. In milk- 
feeding at this time superfat must not be used. Either full milk or 
skimmed milk, properh^ diluted, should be given. If there is a ten- 
dency to relaxation of the bowels, w4th frequent passages, I order the 
use of skimmed milk. Whether the milk shall be pasteurized, sterilized, 
or raw depends upon the conditions referred to under Pasteurization 
and Sterilization (p. 74). 

The Wet-nurse. — Ever}'- summer I have infants under my care who, 
after an attack of diarrhea, cannot take even as small an amount of 
cow's milk as one-half ounce in each feeding. Not a few of the maras- 
mic out-patient infants belong to this class. After a sharp intestinal 
infection, if the child shows inability to take a nutritious diet, a wet- 
nurse may be secured for the well-to-do, but the wet-nurse's milk w^ill 
not always agree, as I have repeatedly found. Children w^ho have been 
very ill with any of the severe forms of acute intestinal disease of sum- 
mer have, as a result, a Yevy weak fat-capacity, and the wet-nurse's 
milk, which perhaps contains 3 or 4 per cent, of fat, produces diarrhea 
sufficient to require its discontinuance. When employing the wet- 
nurse in such cases it is best never to permit the child to have the full 
allowance of breast-milk at first. To a child from three to six months 
of age, for example, it is wise to give two or three ounces of barley-w^ater 
or a 5 per cent, milk-sugar water before each nursing, so that the pa- 
tient will be satisfied with two or three ounces of the breast-milk. 
When cow's milk cannot be given and the nurse's milk does not agree, 
or where for any reason a wet-nurse is not possible, we are called upon 
to furnish other means of nutrition, and this, with our available re- 
sources, will not be of a very high order for infants under one year of 
age. 

Animal Broths. — The animal broths are of very little service. They 
contain but little nourishment even if given in considerable quantity. 



200 THE PRACTICE OF PEDIATRICS 

They produce a decided laxative effect during convalescence from 
diarrhea. They are of value only in small quantities of an ounce or 
two added to the gruel to make it more palatable. 

Cereal Decoctions. — Strong starch foods cannot be digested in suffi- 
cient amount to maintain the nutrition. Dextrinizing processes are 
therefore of considerable service. The starch is thus converted into 
maltose, which is readily assimilable. With this, as with the broth, the 
relaxing effect of the food on the intestine may be felt, frequent bowel 
evacuations being a possible result. The dextrinized gruels, however, 
are always worthy of trial, and they have been of considerable service 
in many cases as a substitute for cow's milk. 

Evaporated Milk. — When breast-milk is not available, canned con- 
densed milk usually answers better than any other means of nutrition, 
being much more easy of digestion than fresh cow's milk. The con- 
densed milk at first is added in small quantities to the cereal water made 
from barley, rice, or granum. No. 1 strength being employed. (See 
formulary, p. 70). One-half dram may be added to every second feed- 
ing for the first day, and on the following day this amount may be 
added to every feeding. The condensed milk usually will be well taken 
and well digested. It is gradually increased until two, three, or four 
drams are added to each feeding. When it seems desirable to use more 
than two drams at each feeding, the fresh or evaporated milk, if ob- 
tainable, furnishes an increased amount of proteid and fat without the 
excessive percentage of sugar. In not a few cases the combination of 
condensed milk and cereal diluent must furnish the nourishment for 
the remainder of the heated term. With the advent of cooler weather, 
one ounce of weak raw milk with the cereal diluent may be substituted 
for one of the regular feedings, and later this may gradually be in- 
creased one-half or one ounce at a time until the raw milk comprises 
one-third of the food mixture. When this point is reached, an attempt 
may be made to replace with raw milk another feeding of the con- 
densed milk. In this way, by carefully watching the case, a gradual 
replacing of the condensed milk by fresh raw milk feeding may success- 
fully be brought about until raw milk only is given. 

Feedings After the First Year. — After the first year similar methods 
may be followed if necessary, although at this age plain milk will usually 
be tolerated earlier, and other means of feeding than the milk may 
be brought into use. Zwieback, bread-crusts, and scraped beef — two 
or three teapoonfuls a day — will often be taken without inconvenience 
when milk in sufficient amount for proper nutrition disagrees. At this 
age the gruels also may be made stronger — No. 2 or No. 3 (see formu- 
lary, p. 70) will often be well borne. An important point to be re- 
membered in feeding convalescents from an acute gastro-enteric dis- 
order is that the food must not be forced, and that the child must be 
fed only in accordance with his digestive capacity. This can best be 
determined by watching the temperature and the stools. The gruels 
as substitute foods, whether alone or combined with condensed milk, 
may be given in quantities equal to those which the child was accus- 



ACUTE GASTRO-ENTERIC INTOXICATION 201 

tomed to take in health, and they may be given at more frequent inter- 
vals, never, however, oftener than every two hours. A child who has 
been fed at four-hour intervals may take the substitute at three-hour 
intervals. If fed at three-hour intervals, he may receive the substitute 
at two or two and one-half hour intervals. When constipation follows 
a sharp attack of diarrhea, an enema may be used not oftener than 
once in twenty-four hours. The patient should not be given a laxative 
unless there is fever for several days after the acute symptoms have 
subsided. 

Eiweiss Milch {Proteid Milk). — In young infants — under nine 
months or thereabouts — the Eiweiss Milch of Finkelstein (p. 65) may 
sometimes be used with good effect. The taste, however, is not 
agreeable to older children, many of whom refuse it. In such instances 
saccharin may be used for sweetening purposes. At first, after the 
acute symptoms have subsided, it is given with barley-water, one part 
of the milk to three parts of barley-water. This may be rapidly in- 
creased to one-half milk and one-half barley. It is not wise in most 
instances to give the milk stronger than this dilution. The Eiweiss 
Milch will be retained and digested more readily than cow's milk, may 
be given in larger daily amounts, and is a valuable means of sustaining 
the child for a few days or a week until cow's milk or condensed milk 
(p. 95) may be tolerated. 

Acute Enteric Intoxication 

This type of intoxication differs clinically from the foregoing in that 
there is no vomiting and rarely fever. Any elevation of temperature 
occurring is usually no more than a sharp rise to 105° or 106°F., and 
is of very temporary duration. In the great majority of the cases there 
is no such elevation, and more often during the entire course the tem- 
perature is subnormal. 

The presence of moderate fever is a favorable sign, and indicates 
a more favorable prognosis. The clinical picture is similar to that of a 
case of gastro-enteric intoxication in that the prostration is extreme, 
the extremities are cold, the eyes sunken, the fontanel depressed, and 
the features drawn and pinched. Convulsions and muscular twitch- 
ings are often present. The mental condition is dulled, and the child 
lies in a semi -stupor, offering little or no resistance when disturbed. 
Diarrhea may be present, or there may be constipation, with or with- 
out tympanites. In some of these patients there is an intestinal 
paralysis sufficient to resist all attempts at an evacuation. I have seen 
such patients die in twenty-four hours from the onset without a degree 
of temperature and without a sign of diarrhea. 

If an evacuation occurs, it is usually a green, mucous stool, which 
may be very offensive, although this is not always the case. 

The milder forms are characterized by an elevation of the tempera- 
ture and varying degrees of prostration. 

Pathology. — The intestinal lesions in these cases are of no conse- 
quence. There is perhaps an area of congestion here and there in the 



202 THE PRACTICE OF PEDIATRICS 

lower ileum or colon, with enlargement of the solitary follicles and 
epithelial desquamation. 

Treatment. — As mentioned above, there may be moderate diarrhea 
or marked bowel inactivity. In both conditions castor oil in doses of 
never less than two drams is to be given. This is followed by discon- 
tinuance of the milk, whether the patient is bottle-fed or nursed. As 
a substitute, barley-water, rice-water, or granum-water No. 1 (p. 70) 
may be given, with salt and cane-sugar or saccharin added for flavoring 
purposes. The treatment of these cases is facilitated by the fact that, 
owing to the absence of vomiting, the food is usually well taken through- 
out the entire illness, the patient ordinarily being very thirsty. In the 
event of excessive diarrhea — a rare condition — the indications for medi- 
cation are the same as those given under Acute Gastro-enteric Intoxi- 
cation (p. 193). Castor oil or bicarbonate of soda (p. 197) is to be used 
instead of calomel at the beginning of the illness. 

Intestinal infection with defective bowel action (paralytic ileus) often 
gives us our most difficult cases and requires different treatment. In 
this type poisons generated in the intestinal contents or elsewhere 
seem to be of such a nature as to cause a partial paralysis of the small 
intestine, so that often, only with the greatest difficulty, can an evacua- 
tion be induced. So difficult is this, in fact, that the possibility of an 
acute peritonitis or an intussusception may occur to the physician. It 
is very necessary to maintain bowel action and to prevent the accumu- 
lation of gas, which, by distending the intestine, increases the tendency 
to constipation. Several cases of this nature, with high temperature, 
sluggish bowel action, and intense prostration, are seen by me every 
year. 

Illustrative Cases. — A case in point is that of a female infant nine months of age 
who had been most difficult to feed. In July she developed a sudden high fever of 
105°F. and convulsions, which were followed by muscle twitchings, head-rolling, 
and marked prostration. The temperature was uninfluenced by local means, 
although there was no diarrhea or vomiting. The attending physician, anticipat- 
ing intestinal infection, gave calomel in divided doses with frequent bowel irriga- 
tion. Foul-smelhng fecal material came away with the irrigation, but the tem- 
perature and the nervous symptoms persisted; in fact, the condition became 
worse. I first saw the child when she had been ill ten or twelve hours, and directed 
that one-half ounce of castor oil and a high irrigation of normal salt solution at 
80°F. be given. As a result of the treatment there was .one small green 
movement in addition to what came away with the irrigation, which was con- 
siderable. The patient was somewhat relieved and the nervous symptoms 
measurably subsided, though the temperature still ranged between 104° and 
105°F. As a result of the calomel, 1^ grains of which had been given, and the 
half-ounce of oil, a free diarrhea was expected. It did not, however, occur. ^ I then 
directed that one-half ounce of castor oil be given daily in addition to the irrigations 
every eight hours. This was followed by a slight improvement in the symptoms, 
but five days of the treatment were required, one-half ounce of oil and one grain of 
calomel being given daily, with abdominal massage, before the resulting peristalsis 
was sufficient to relieve the intestine of its contents. After the establishment of 
free bowel action the child recovered. 

A similar case which resulted fatally was seen in consultation. In this patient, 
a girl eight years old, the toxemia was intense. There appeared to be almost com- 
plete paralysis of the small intestine. Only sniall, very foul evacuations could be 
induced, in spite of the most active local and internal measures. The child died 
from toxemia before free bowel action could be established. 

The management of these cases of the inactive type is partially 



ACUTE GASTRO-ENTERIC INTOXICATION 203 

illustrated in the histories above given. Our efforts are to be directed 
toward supporting the patient by the use of stimulation, given hypoder- 
mically or by the stomach, and by the use of a milk-free diet, powerful 
laxatives, and frequent colon flushings. Castor oil may be required 
repeatedly, and should be given freely in doses of at least one-half 
ounce every twelve hours, until four or five passages in twenty-four 
hours result. Bicarbonate of soda (p. 197) is given with satisfactory re- 
sults in cases of this type. While the fever, prostration, and bowel inac- 
tivity persist, it is necessary to continue the irrigations. In a few cases 
apparently better results were secured by using for the irrigations cold 
water (70° to 80°F.), with the addition of Epsom salts, one ounce to the 
pint. 

Stimulants. — Because of the tendency to convulsions and nervous 
irritability, strychnin should not be given. The tincture of strophan- 
thus answers better than any other heart stimulant. Alcohol should be 
used only under the most urgent conditions of prostration. Atropin 
sulphate, from J^ooo to J^oo grain given hypodermically, is probably 
our most valuable means of stimulation. It may be repeated at four- 
to six-hour intervals. A combination of tincture of strophanthus and 
brandy, or digitalin and brand}^, given hypodermically is of value. 
For a child six months of age 20 minims of brandy with 1 drop of tinc- 
ture of strophanthus, or 20 minims of brandy with J^oo grain digitalin, 
may be given and repeated every two hours if necessary, according to 
the requirements of the case. After the first year children may be 
given as much as 3^oo grain of digitalin or 2 drops of the tincture of 
strophanthus. 

Irrigation of the colon (p. 793) is a measure of inestimable value, 
both for its immediate local effect and also for increasing general peri- 
stalsis and thus emptying the small intestine. An increase of the peri- 
stalsis is sometimes well secured by the following procedure : After the 
colon is washed with a normal salt solution at a temperature of 95°F., 
the tube is introduced as far as possible and 8 ounces of water at 60°F. 
is allowed to escape. The tube is immediately removed and an at- 
tempt is made, by elevating the buttocks and pressing them together, 
to have the child retain the solution for a few moments. 

In using nutrient enemata and in colon flushing for purposes of 
supplying fluids to the circulation we have found that the solution is 
best retained when introduced warm — at a temperature of about 
100°F. The cooler the solution, the more quickly is it expelled through 
exciting peristalsis. This fact may be taken advantage of in these 
cases of bowel inactivity. After an enema of cool water peristalsis of 
the small intestine will often result in the passage of a considerable 
quantity of its contents into the colon, to be expelled later with the 
water. This I have frequently demonstrated. The action of the cool 
water will be further assisted by light abdominal massage maintained 
after the tube is removed. Recovery may follow the clearing-out of 
the intestine, or an ileocolitis may result, as in gastro-enteric intoxica- 
tion. The process of transition may require but a surprisingly short 



204 THE PRACTICE OF PEDIATRICS 

time, and if recovery is not prompt, an ileocolitis will almost certainly 
be the outcome. 

Upon resuming the milk diet the precautions relating to the use of 
cow's milk, referred to under Acute Gastro-enteric Intoxication (p. 
193), must be observed. 

ACUTE INTESTINAL INDIGESTION 

This disorder is referred to first because, according to my observa- 
tion, of all the intestinal disorders, it is the most frequently seen. 
Because its importance is not recognized the prophylaxis and treatment 
receive but little consideration. The proper appreciation and man- 
agement of a disordered intestinal function are essential to the solution 
of that most important problem — summer mortality from diarrheal 
diseases. As pointed out elsewhere, the most fertile field for later dis- 
ease is furnished by the intestine which is persistently deranged. 

In June the mortality from acute intestinal disease in Greater New 
York in children under two years of age is usually but 300 to 500 less 
than in August. The high June mortality has been explained by the 
fact that the list included many cases of malnutrition and marasmus, 
but it must be remembered that the list includes also cases with dimin- 
ished intestinal resistance, which are ready victims to the almost invari- 
able exposure, through infected food, to which every bottle-fed infant is 
subjected at some time during the summer, when heat and humidity 
aid in lowering the general vitality. A close investigation of hundreds 
of cases of severe acute intestinal disorders of infants has shown that 
a great majority are not so acute as a superficial history would indi- 
cate. A complete history in a case of acute gastro-enteric intoxica- 
tion (cholera infantum), or in one of apparently severe intestinal in- 
fection with resulting colitis, or one of acute colitis (dysentery), will 
show that the child had defective intestinal digestion during the pre- 
vious cold months, and that the grave condition which he presented 
when brought for treatment had been preceded for two or three or more 
days by simple diarrhea, probably without vomiting and with little 
fever. The fact that the patient did have green passages and did have 
diarrhea proves the existence of intestinal indigestion before the urgent 
symptoms of fever and prostration developed. In about 1 per cent, of 
the cases of severe gastro-enteric diseases of children in summer the 
onset is sudden without warning, and with urgent symptoms. 

Symptom.s. — Temperature is usually present in varying degree. 
It may be as high as 104° or 105°F. There is restlessness, abdominal 
pain, and moderate prostration. The stools are frequent, undigested, 
green, and may contain mucus. 

Duration. — Properly managed, the case has but a few days' dura- 
tion. The temperature readily subsides, and the child soon shows 
evidence of displeasure at the reduced diet. 

Prognosis. — The condition is serious only in the sense that it may 
be the starting-point of severe intestinal intoxication. Properly treated 
cases present few dangers. 



PERSISTENT INTESTINAL INDIGESTION 205 

Treatment. — The time to treat these cases of intestinal indigestion, 
in order to secure most effective prevention of severe toxemia and grave 
lesions, is before the physician sees the patient. The reduction in the 
mortality rests in the education of the mother to the point of realizing 
that a loose green stool is a danger-signal. When it occurs, she is to 
give a dose of castor oil (two teaspoonfuls), stop the bottle or stop the 
nursing, and give the baby boiled water or barley-water until the physi- 
cian can see the patient. Any physician who has children under his 
care, whether in hospital, institution, out-patient, or private practice, 
and who does not so instruct the nurse or mother, fails in his obligation 
as a practitioner of medicine. 

In the Breast-fed.' — Intestinal disease of severity in infants fed en- 
tirely on breast-milk is exceedingly rare. With a breast-fed baby it 
may be necessary to discontinue nursing for from twelve to thirty- 
six hours. The child is given one or two drams of castor oil, and barley- 
water or rice-water No. 1 (see p. 70), to each pint of which 3^^ or J^ 
ounce of cane-sugar is added. While nursing is discontinued the 
breasts should be pumped at the regular nursing hour so as to keep up 
the flow of milk and relieve the pressure. Rarely will other treatment 
be required. 

The Bottle-fed. — With the bottle-fed greater caution will be necessary. 
The management consists in continuing the carbohydrate diet, which 
the well-trained mother has instituted, until the stools approximate 
the normal. This may necessitate an abstinence from milk for three 
or four days, by which time it may usually be resumed. The milk 
should always be given in reduced quantities for the succeeding day. 
One-half ounce of skimmed milk may be added to every second feed- 
ing or to every feeding of the gruel. If it is well digested and causes 
no return of the diarrhea, the amount of milk may be increased ten- 
tatively every day or two by the addition of one-half ounce to each 
feeding. 

In some of these cases the diarrhea without fever will continue. 
In such instances the administration of 10 grains of bismuth subnitrate 
(Squibb 's), with 3^ to 3^^ grain of Dover's powder at two- to three- 
hour intervals, aids materially in establishing the normal intestinal 
function. 

PERSISTENT INTESTINAL INDIGESTION 

The greater part of this subject has been covered in the considera- 
tion of the management of malnutrition and marasmus. It is again 
referred to here in order to call attention to those conditions which, 
though mild in character, constitute so important an etiologic factor 
in the acute intestinal diseases of summer. There is perhaps not enough 
bowel disturbance to interfere with the nutrition, but we have learned 
that a considerable part of the summer mortality of acute intestinal 
diseases occurs in children who have a reduced intestinal resistance 
as a result of persistent intestinal indigestion. 

A considerable number of infants do not have a normal bowel evac- 



206 THE PRACTICE OF PEDIATRICS 

uation even for two days out of ten. There is constipation, which is 
neglected, or there is passage of undigested or loose stools. In some 
cases constipation alternates with diarrhea. Occasionally there is a 
sharp attack of diarrhea with fever. In getting the history of our cases, 
regardless of the nature of the illness, we often learn that the infants- 
have undigested stools. There is a tendency to an unstable intestinal 
equilibrium. This condition of intestinal indigestion is almost without 
exception due to errors in diet involving the habitual giving of unsuita- 
ble articles of food, or of food too strong, or feeding at too short 
intervals. 

Treatment. — The management of each case is determined by the 
age of the patient and the conditions of the family, and is discussed 
in the sections relating to Nutrition, Substitute Feeding, and Modi- 
fication and Adaptation of Foods. 

PERSISTENT INTESTINAL INDIGESTION IN OLDER CHILDREN 

In these cases there is a disturbance of function and there may be 
sufficient absorption of toxins of an unknown nature from the intestinal 
canal to produce a wide range of symptoms. Whether this causes 
pathologic conditions in other organs it is not possible to state. It is 
assumed, however, that such is the result. Comparatively little atten- 
tion appears to have been given the subject. There is no doubt what- 
ever that it is a factor of great importance in the nutritional and 
so-called functional nervous disorders of childhood. One reason why 
little attention has been called to the intestinal tract as an etiologie 
factor is perhaps because the child is not necessarily constipated. In- 
testinal toxemia may exist with one or two apparently normal passages 
daily, and even without the presence of indican in the urine. 

Pain is not a necessary symptom. It is occasionally present, how- 
ever, as is also abdominal discomfort involving a sensation of con- 
striction and pressure. 

In my cases the conditions in which intestinal toxemia has seemed 
to play a part sufficient to form a symptom-complex have been habitual 
headache, disorders of speech, choreic in character, secondary anemia, 
habitual sleep-talking, sleep-walking, and general irritability without 
apparent cause. Well children are naturally bright and happy. When, 
a child is persistently cross and irritable, he is not a well child. Chronic 
papular eczema has proved to be of intestinal origin in a considerable 
number of my cases, particularly among the out-patient class. The 
condition often regarded and treated as malaria is not infrequently^ 
due to intestinal toxemia. Fever of a degree or two may be present 
for protracted periods. Nearly every case which has come under my care 
had been given at some time or other a course of quinin. Such a pa- 
tient is very apt to be habitually tired and languid. He may be fairly 
bright early in the day, but in the afternoon he yawns and complains 
of being tired and sleepy. The blood examination fails to reveal signs 
of malarial infection, and quinin in full doses furnishes no relief. The 



PERSISTENT INTESTINAL INDIGESTION 207 

appetite may be satisfactory, the tongue may show no signs of digestive 
disorder, although such is rarely the case. The tongue is usually coated 
and the appetite capricious. The symptom-complex which suggests 
to the mother the thought of worms is usually the manifestation 
of intestinal toxemia. 

Illustrative Cases. — An interesting case of this nature came under my care a few 
years ago. The boy, aged three years, highly nervous and irritable, was afflicted 
with day terrors — pavor diurnus. The attention of the nurse was attracted to the 
condition by the boy, who asked that the "bugs" be removed from his lap-robe 
when he was in his go-cart. The time was mid-winter, and there were no bugs 
present. I fortunately saw the boy on one of these occasions and asked him to 
pick up a bug, which he tried to do with his fingers. He could not understand 
why he could not catch them. In this child the tongue was heavily coated and 
there was moderate constipation, a laxative being required every third day. There 
was an excess of indican in the urine. The boy was taking a large amount of rich 
cow's milk daily. After stopping this, a full dose of rhubarb and soda was given 
daily and he was well in a week. 

A boy five years old was brought to me because of disturbance of speech. He 
was normal until three and one-half years of age, when he had difficulty in the 
formation of entire words. This had increased with the development of other 
nervous phenomena. There was marked incoordination in speech — dysarthria — 
due to choreic movements evidently of the tongue and laryngeal muscles. The 
boy was exceptionally well nourished and there was an absence of choreic move- 
ments in other parts of the body. The knee reflexes were considerably increased. 
He was easily excited. Hard play was followed by restless nights, and he talked in 
his sleep every night, regardless of the habits of the day. _ Inquiry into the diet 
failed to reveal any grave errors. He drank one quart of milk daily, although milk 
had never agreed with him as an infant. The bowels moved once daily. The move- 
ments were often of foul odor, and the mother stated that she was satisfied they 
were too small. The case after three weeks showed striking improvement on a 
diet without milk, with a daily laxative, and made a complete recovery in three 
months. 

A third patient was a girl six years of age who lived in the best surroundings, 
in a country district. She was pale, rather thin, and below weight for her age. 
She had been chronically tired and irritable for two years. The blood showed 
the existence of a secondary anemia, and the urine contained a marked excess of 
indican. She had been taking quantities of quinin. There was no constipation. 
Her appetite was indifferent. She favored milk and was paid for drinking extra 
quantities of it, about two quarts daily being taken. Marked improvement fol- 
lowed the withdrawal of milk from the diet and the use of laxatives, after which 
she passed from my observation. 

In many cases of this nature there is a milk intolerance, perhaps 
both for the fat and protein. 

Treatment. — In my experience the management of these cases, 
which has been most successful, has consisted in the discontinuance 
of cow's milk, with the further dietetic restriction to but one egg every 
second day, and meat but once daily. Cereals, fruit, and vegetables 
are taken as suggested in the dietary (p. 105). The use of green vege- 
tables is particularly encouraged. In place of cow's milk, malted milk 
is given, and to facilitate the bowel action a raw apple is given in the 
middle of the afternoon. The patient takes an after-dinner rest for 
an hour or two. If constipation is obstinate, rhubarb and soda of the 
following strength are used : 

I^ Pulveris rhei gr. iv 

Sodii bicarbonatis gr. viij 

Synipi rhei aromatici 5ss 

Aquae q. s. ad 3 J 

M. Sig. — One teaspoonful once or twice daily. 



208 THE PKACTICE OF PEDIATBICS 

If the patient can take a capsule, I prefer the following for a child 
from five to eight years of age : 

I^ Tincturse belladonnae gtt. ij 

Tincturse nucis vomicae gtt. iv 

Extract! cascarse sagradae gr. j-iij 

Sodii bicarbonatis gr. iij 

M. ft. capsula no. i. 

Sig. — To be taken at bedtime. 

The medication may be continued for three or four weeks, after 
which time one dram of the syrup of the hypophosphites (Gardner's) 
may be given three times a day. This may be alternated with: 

I^ Ferri et ammonii citratis gr. xxiv 

Elix. simplicis 5j 

Aquae q. s. ad §iv 

M. Sig. — One teaspoonful three times daily after meals. 

In the event of constipation persisting after the use of the laxative, 
the oil treatment (p. 241) may be brought into use and continued until 
the condition is relieved. 

MECHANICAL AGENCIES IN THE INTESTINAL TRACT AS A CAUSE 
OF DIGESTIVE DISTURBANCES 

Observation with the Roentgen ray in association with constant 
clinical supervision has opened up an entirely new field in the etiology 
of the persistent intestinal disorders in children. As a result of 
abnormalities in structure and in the relations of various portions of 
the intestine there results a derangement of function due to disturbed 
physiological and chemical processes, the result being in many 
instances faulty nutrition, defective growth and inferior general 
development of the child, both physical and mental. 

Mechanical defects of the intestine such as ptosis of the colon, 
dilatation of the colon, dilated caecum and the long sigmoid are the 
abnormalities most frequently encountered. The ptosed colon is 
usually associated with dilatation and ptosis of the stomach and is 
probably secondary to that condition. 

The long sigmoid (Figs. 19, 20, 21, 22) is of congenital origin. The 
dilated colon and caecum appear to be dependent upon the accumu- 
lation of feces and gases brought about by the obstruction occasioned 
by the long sigmoid, with its angulation and defective peristalsis. 

Symptoms. — The symptoms referable to the above abnormalities 
are repeated attacks of acute indigestion with vomiting, abdominal 
distention, habitual or intermittent, intestinal colic, constipation which 
may be extreme, diarrhea alternating with constipation, or habitually 
loose mucous evacuations, periodic fever with intestinal association. 

In addition to these active manifestations the patients are usually 
anemic — there is secondary malnutrition, the child 's mental equilibrium 
is easily disturbed, they are apt to be unhappy irritable children, 
they sleep poorly and their appetite is capricious. A few show defects 
in stature. That arrested growth and anemia may be the result of 



MECHANICAL AGENCIES IN THE INTESTINAL TRACT 



209 



abnormal intestinal function is readily understood when one realizes 
what a vital part the intestine plays in growth and development. 




Fig. 19. — Female 



years. Elongated sigmoid. Passes above level of 
transverse colon (LeWald). 



The history of the case represented in Fig. 19 is as follows: A girl 
aged 9 years and weighing 54 pounds showed hemoglobin 40 per cent. 
14 



210 



THE PRACTICE OF PEDIATRICS 



and red blood cells 4,000,000. She was of delicate appearance, had 
moderate malnutrition and showed very slow gain in weight. About 

r 




Fig. 20, — Female aged 23^ years. ''Double-barreled" transverse colon. 
Appearance due to elongated sigmoid jBexure passes across to right side of abdomen 
and above crest of right iliac bone (LeWald). 

every two months she had so-called bilious attacks simulating recurrent 
vomiting. There was high fever and she was in bed for several days 
each time. The bowels were habitually constipated and daily medi- 



MECHANICAL AGENCIES IN THE INTESTINAL TRACT 211 

cation was required. The breath was offensive. The Roentgen ray 
revealed ptosis of the stomach and that it failed to empty itself in 
seven hours. There was marked ptosis of the transverse colon and 
marked elongation of the sigmoid. 




Fig. 21.— Female aged 15 months. Figure of 8 sigmoid flexure (LeWald). 

Fig. 20. A girl, aged 2J^ years, weighing 25 pounds, showed hemo- 
globin 55 per cent, and red blood cells 4,600,000. There was moderate 
malnutrition. She had three convulsions of gastro-intestinal origin in 
the previous year. There was habitual constipation and medication or 
an enema was required daily. The urine showed a moderate amount 



THE PRACTICE OF PEDIATRICS 




Fig. 22. — Male aged 3^ years. Elongated sigmoid. One of the most extreme 
types encountered. Roentgenogram by Dr. L. T. LeWald. 



MECHANICAL AGENCIES IN THE INTESTINAL TRACT 213 

of acetone. The Roentgen ray revealed an elongated sigmoid passing 
2 inches above the umbilicus. When the child was in the prone posi- 
tion the sigmoid passed to the right as far as the abdominal wall. 

Fig. 21. A girl, 15 months of age, was brought from a distant 
city because of loose evacuations containing blood and mucus. This 
condition had existed for one month and had been preceded by the 
most obstinate constipation. Medication had been required daily. 

Fig. 22. A boy, 3J^ years of age, weighing 32 pounds (under 
treatment at the present time) represents a markedly elongated and 
prolapsed sigmoid. 

The history given by the mother is as follows: Boy has had 
acute gastro-intestinal attacks since birth, vomiting, diarrhea and fever, 
acute seizures lasting 3 to 4 days during which he loses a pound or 
two of weight. During the past year there has not passed two months 
without such an illness. Between attacks is constipated and requires 
medication. Has frequent pains in abdomen and appendicitis 
has been diagnosed. Breath habitually offensive, tongue habitually 
coated. Some of these seizures have been diagnosed as colitis because 
of the presence of considerable quantities of mucus. Very irritable 
and very unhappy in disposition. Abdomen distended a greater part 
of the time. 

Constipation alone, or with abdominal distention, are present 
in nearly all. In those with diarrhea or habitually loose mucus 
evacuations there is always a history of previous constipation, and 
the relief of the constipation is the keynote of the management. 

Treatment for Constipation. — The selection of suitable food for a 
given case plays a large part in the management. For the constipation 
the following dietetic regulations are advised: White bread, toast 
and crackers are omitted. Oatmeal, cornmeal, hominy, cracked wheat 
and the coarse cereals are allowed. Potatoes, rice, milk and eggs are 
given sparingly. Milk is often replaced by malted milk. Green 
vegetables are given twice a day. Stewed or raw fruits are given the 
preference as desserts. Fresh meats ^nd fish are allowed. Whole 
wheat bread and oatmeal crackers are advised. Raw fruits are given 
with the stomach supposedly empty, an hour to an hour and a half be- 
fore meals. We have found the giving of raw fruits with the stomach 
empty one of the most valuable dietetic means of managing constipa- 
tion. We are speaking now of those cases without stomach in- 
volvement. 

Enemata for Temporary Purposes. — An enema may be employed 
but it should never be given habitually. I have seen marked dilata- 
tion of the rectum as a result of frequent enemata. 

Massage. — Properly applied, daily massage is almost indispensable 
in obstinate cases. Massage and suitable diet may have to be contin- 
ued for several months. 

Medication. — Olive oil and liquid alboline are useful in connection 
with other laxatives, but rarely sufficient when used alone. What 
is required is an active peristalsis. In using laxatives however, care 



214 THE PRACTICE OF PEDIATRICS 

is to be exercised to avoid purgation. Our best results have been in 
the use of fluid ext. aromatic cascara sagrada three times daily- 
after meals, given in doses sufficient to produce one or two free evacua- 
tions daily. Given with an oil and with the aid of massage the cascara 
may be gradually reduced. . It should always be given after each meal 
no matter how small the daily dosage. 

Diarrhea. — The child with diarrhea or with habitually loose evacua- 
tions perhaps but one or two daily is best treated by omitting stewed 
fruits and green vegetables entirely from the diet. Milk given these 
patients should be skimmed and boiled. My earlier results with this 
type of case were very satisfactory. Two cases under treatment at 
the present time, both of which have greatly elongated sigmoids, are 
proving intractable and not much progress is being made with diet and 
medication. Surgical procedures may be required in these patients. 

Although there may be a displaced colon or an elongated sigmoid, 
and a history of previous constipation, the stool should always be 
examined in diarrhea for other possible causative factors. 

COLIC 

Few children complete their first year without having severe 
attacks of intestinal colic. In some cases the child thrives in spite of 
the attacks, in others such a grave degree of indigestion exists that the 
condition may prove most serious. The character of both human and 
cow 's milk, its ready decomposition in the intestine, with the formation 
of gas, together with the lack of development of the infant's digestive 
apparatus, explain in no small degree the frequency of colic in the young. 
When cow 's milk is used as in the bottle-fed, we are dealing with a sub- 
stance foreign to the infant 's digestive apparatus, and often colic is the 
outcome. Any condition that will give rise to indigestion may, of 
course, be a cause of colic. Children who take too much milk, too 
strong milk, or who take milk too frequently are the usual subjects 
of colic. Probably the most frequent cause of colic is indigestion 
of the proteid of the milk. Either the proteid is in excess or the child 
has poor proteid capacity. Not a few cases of colic are due secondarily 
to defective bowel action. A passage occurs each day, but in too small 
amount. There is a continual fecal residue in the intestine which under- 
goes decomposition with gas-formation. Cold feet are often associated 
with colic. Fright, anger, fatigue, excitement — any condition, in short, 
which may make a sufficiently unfavorable impression upon the child 's 
nervous organism — may produce indigestion and colic. 

Likewise any adverse nervous mental state in the mother may pro- 
duce colic in the breast baby. Constipation in the mother is not an 
infrequent cause. 

Infants who have colic habitually will more often have it late in 
the day than at any other time. 

Colic may be caused by an elongated sigmoid which forms angula- 
tions and prevents the natural passage of gas. Fig. 12 represents a 
case of most obstinate and severe colic. The patient, a girl, aged 



COLIC 215 

33^^ months, weighing 10 pounds, was suffering from malnutrition, 
extreme cohc night and day, and constipation. An enema was re- 
quired daily. The Roentgen ray revealed hyperperistalsis of stomach. 
The sigmoid was elongated, passing 1 inch above the umbilicus, and 
the stomach was distended with gas. 

Diagnosis. — While the diagnosis is usually a simple matter it must 
be remembered that intussusception (p. 233) and appendicitis (p. 252) 
may cause symptoms identical with colic. 

Treatment. — Repeatedly I have had under my care nursing babies 
who suffered from habitual colic and who recovered after the regulation 
of the mother's bowels by exercise, diet, and medication. In breast- 
fed cases in which the mother's milk upon repeated examination 
proves too strong and the child suffers from daily colic, a dilution of 
the milk may be made by the use of plain water or barley-water, from 
one-half ounce to one and one-half ounces of the diluent being given 
before each nursing. In addition the bowels of the colicky infant 
should be made to move at least twice daily, morning and evening. 
When this does not take place readily a simple laxative such as milk 
of magnesia, one-half to one teaspoonful, or 10 to 30 drops of aromatic 
cascara sagrada, may be given daily. Under no condition should a 
child subject to colic be allowed to go without a bowel evacuation for 
more than twenty-four hours. 

Diet. — The dietetic management of colic in the bottle-fed consists 
in adapting the food to the child 's digestive capacity. The bottle baby 
may have habitual colic moderately and thrive, but is receiving an 
imperfectly adapted food. Here, as in the breast-fed, the condition is 
usually dependent upon an excessive casein supply or a diminished 
casein capacity. The matter of the adjustment of cow's-milk proteid 
in indigestion is discussed in detail under Milk Adaptation (p. 62). 
It is sufficient to say that the colicky bottle baby should have long 
intervals between feedings — usually one-half hour longer than other- 
wise allowed. Digestion is slow in many of these cases, although 
in other respects they may be healthy children. In some the indigestion 
and pain are so severe that a perfect adaptation of cow 's milk is impos- 
sible, and some other food than cow's milk will be required. The 
prevention of colic, then, it will be seen, rests upon a proper adjust- 
ment of the food. 

Enemas. — The immediate attack is usually best relieved by the use 
of an enema at 110°F. of a normal salt solution or of soapsuds, which, 
by inducing a movement of the bowels, allows the gas to escape. 

Medication. — A soda-mint tablet dissolved in one ounce of hot 
water given in one-teaspoonful doses repeated at five minute intervals 
is sometimes efficacious. For a child under one year of age 3 drops of 
spiritus setheris compositus (Hoffmann 's anodyne) may be given in 2 
teaspoonfuls of hot water and repeated at ten-minute intervals. From 
5 to 10 drops of gin, when given in 3 teaspoonfuls of hot water, may 
be used, and repeated in from ten to fifteen minutes if the attack 
continues. 



216 THE PRACTICE OF PEDIATRICS 

Hot Applications. — Hot applications to the abdomen are often grate- 
ful to the patient. For this purpose 10 drops of turpentine in one quart 
of water at 120°F. may be used with benefit. A flannel is wrung out 
of the water or the solution and applied over the abdomen and covered 
with a dry piece of flannel. The dressing may be changed every ten 
or fifteen minutes. 

Opium and its derivatives should not be used in the treatment of 
colic. This drug may relieve the pain temporarily, but it aggravates 
the condition to which the colic is due. 

PREVENTION OF THE ACUTE INTESTINAL DISEASES OF THE SUMMER 

Preventive medicine, so called, is at the present time engaging 
the attention of the best medical minds. The acute intestinal diseases 
of summer, with their large infant mortality, offer a better field for 
life-saving measures than does any other department of pediatrics. 

Potent etiologic factors in summer diarrhea are unfavorable climate 
and unfavorable environment. In the class which furnishes the largest 
mortality, climate cannot be changed for a sufficient number to exert 
any great influence on the general mortality. Through education 
the environment may be radically improved, but it cannot be changed. 
The hot months come and the tenement child must remain at home. 
Excursions and outings of various kinds are valuable in a small way to 
comparatively few, as the child must return to the tenement home at 
night or after a few days^ absence, so that in our consideration of this 
class of patients in large cities we must accept unfavorable environment 
and hot weather — in other words, we must treat these cases in their 
homes. Those more fortunately situated, who can have the advantage 
of the country and intelligent care, are proportionately less liable to 
diarrheal diseases. Other than climate and environment, the determin- 
ing etiologic factors among all classes are: first, a disordered gastro- 
enteric tract; second, infected food; third, faulty feeding methods; 
fourth, an absence of appreciation on the part of the parents and 
physicians of the fact that an attack of diarrhea or vomiting, or even a 
green, undigested stool, occurring in an infant under eighteen months 
of age during hot weather, is to be looked upon as a serious matter re- 
quiring prompt attention. 

Children as well as adults are frequently exposed to disease from 
sources of which they are ignorant, because their power of resistance 
is insufficient for their protection. With milk, the most readily in- 
fected of all nutritional substances, as the chief article of diet, it may 
safely be assumed that few infants will pass through the heated term 
without being subjected repeatedly to infection from bacteria suf- 
ficient to produce grave illness. An infant's best safeguard against in- 
testinal infection is a strongly resistant gut, which is best secured by 
the absence of digestive disturbances at all seasons of the year. Feed- 
ing and intelligent management generally throughout the year has, 
consequently, a decided bearing upon summer mortality from intes- 
tinal diseases. 



PREVENTION OF ACUTE INTESTINAL DISEASES OF SUMMER 217 

I have had abundant opportunity to observe that the children who 
have had frequent attacks of intestinal indigestion during the colder 
months furnish our severe cases during the summer. A most important 
feature, then, in prophylaxis is to teach the mother how to feed and 
care for the child all the year round, in order that, by keeping well, 
the child may maintain a high grade of intestinal resistance. 

Dispensary Rules of Universal Application. — At the out-patient 
department of the Babies' Hospital and the New York Polyclinic, I 
have had abundant opportunity to come into close contact with a 
great many tenement mothers and tenement children. At these in- 
stitutions we have a clientele fairly regular in attendance, year after 
year; for as one baby after another appears in the family, each is 
brought to us for treatment. At these dispensaries there is a surprisingly 
low summer diarrhea mortality, because we teach the mothers how to 
feed and care for their children all the year round. They are taught 
the value of fresh air, the use of boiled water as a beverage, and the bene- 
fits of frequent spongings on hot days. Both private and dispensary 
mothers whose children are under my care are given pamphlets of in- 
struction and also oral teaching bearing on these points, and particularly 
those relating to the care of the feeding bottle and the milk. In case 
special articles of diet are to be given, the mothers are taught how to 
prepare them. Written directions are always given covering the point; 
nothing is left to the memory. Each mother and nurse has it im- 
pressed upon her that she must wash her hands in soap and water 
before touching the baby 's food or feeding apparatus for any purpose, 
and that there must be a covered vessel in which the soiled napkins are 
to be kept until washed. At the first sign of intestinal derangement, 
regardless of the season of the year, they are taught to stop the milk 
at once, to give instead a cereal water, such as barley-water or rice- 
water, and a dose of castor oil. It is impressed upon them that, in 
winter as well as summer, a green, watery stool means that the baby 
is ill and needs treatment. When the mother learns the above lesson 
for December, January, and March, she will not forget it in July. 
Furthermore, as a result of the immediate correction of a child's 
digestive disorder during the winter months, the digestive tract affords 
a much less fertile field for pathogenic bacteria during the summer. 

Prompt Treatment Essential. — Comparatively few cases of intestinal 
diseases have pronounced toxic symptoms at the outset. At first 
there are evidences of a milk infection only. There may be vomiting, 
several green, watery stools, and a slight elevation of temperature, 
or the symptoms may be still more mild — only one or two loose green 
defecations. Prompt treatment at this time, even in a crowded tene- 
ment, usually means prompt recovery. When treatment is delayed 
and the administration of milk is continued, severe toxic symptoms 
and intestinal lesions are almost invariably the result. 

New York City Experiments. — An interesting demonstration of 
what may be accomplished by proper care was made under the direc- 
tion of Dr. William H. Park, of the New York Health Department, 



218 THE PRACTICE OF PEDIATRICS 

during the summer of 1902. Fifty tenement children, ranging from 
three to nine months of age, were selected for the experiment. These 
children were all fed on the Straus milk. They were visited two or 
three times a week by physicians especially assigned to them. The 
mothers were carefully instructed as to the care of the milk and the 
feeding apparatus, and in other necessary details. With the first 
signs of illness, the milk was to be stopped, the physician notified, 
and suitable treatment instituted. Among these 50 tenement children, 
all under one year of age, all bottle-fed, selected at random, there was 
not one death during the summer. This valuable observation bears 
out my contention that the deaths from summer diarrhea among tene- 
ment children may be greatly reduced by the use of good milk given 
under proper supervision, supplemented by prompt and competent 
medical care at the first sign of illness. Perhaps in 1 per cent, of the 
cases of summer diarrhea a very severe direct infection is evident, 
and the condition of the patient is very grave from the onset. In the 
remainder the invasion is gradual; and, if the warnings are heeded, 
the illness will usually terminate quickly in recovery. 

How to Secure Good Milk. — To those of my patients of the bet- 
ter class who go to the country for the summer, and who have cows 
of their own in ,order to control their milk-supply, I give the following 
directions: Before milking, the udders and belly of the cow should be 
wiped with a damp cloth to remove clinging particles of dirt. It is 
in these droppings containing manure that the most dangerous forms 
of bacteria of decomposition enter the milk. The milker should wash 
his hands before milking. The first few jets of milk, coming from the 
ducts near the openings, are apt to be swarming with bacteria, and are, 
therefore, discarded. Immediately after the milking the milk should 
be strained through several thicknesses of cheese-cloth, or through ab- 
sorbent cotton, into an ordinary milk bottle, which is at once placed in 
a pail of cracked ice. Such simple care as this, even on an ordinary 
farm, gives a very low bacteria count. As may readily be seen, it is 
attended with v.ery little trouble and expense. Different dairies through- 
out the country, which are located near my patients for the summer, 
meet the above requirements, for which they receive an extra compen- 
sation of five or six cents a quart. 

The Necessity for Education. — The suggestions we have offered are 
all included under the one general heading of Education. The mother 
must be educated how to live, how to care for the baby, how to 
clothe and bathe him during the summer. It must be impressed upon 
her that he needs all the fresh air available. She must be educated to 
the point of knowing what to do at the first sign of threatened disease. 
Municipalities must be educated to appreciate their responsibility as 
factors, negative or positive, in the summer mortality. The farmer 
must be educated to produce safe milk, and the consumer must be 
educated to appreciate its value and pay for it. Above all others, the 
physician must be educated along these lines so as to be able to teach 
the mothers how to do right in the care of their children all the year 
round. 



VOMITING 219 

VOMITING 

While vomiting does not constitute a disease in itself, it is a condi- 
tion of such frequency in children, and occurs in such widely varying 
circumstances, that any work relating to diseases of children, would 
be incomplete without its consideration. 

The most frequent causes of vomiting depend solely upon the 
functions of the stomach. When the stomach is overfilled, vomiting 
may result. When substances sufficiently irritating come in contact 
with its lining mucous membrane, whether they are swallowed as 
such or are produced by fermentation or some other change in the 
stomach contents, they are ejected. When there is an inflammatory 
involvement of the mucous membrane of the stomach, either acute or 
chronic in character, the organ becomes intolerant of the blandest of 
fluids. Another condition involving the structure of the stomach, but 
only occasionally seen in children, is ulceration, which is usually 
multiple. Vomiting is the prominent, in fact the only, symptom. 

Dilatation of the Stomach. — In this condition the food does not 
pass readily into the intestine, but remains in the stomach and under- 
goes changes which produce sufficient irritation to cause vomiting. 

Pyloric Stenosis. — In pyloric stenosis the food is prevented by 
the narrow pyloric opening from passing into the intestine, one feed- 
ing follows another, the stomach becomes overloaded, and, by reason 
of fermentative change in the residue, sufficient irritation is produced, 
in connection with the spasmodic contractions of the stomach peculiar 
to the condition, to induce vomiting. 

Causes Remote from the Stomach. — In intestinal obstruction, 
whether due to intussusception, volvulus, peritonitis, or impacted 
feces, vomiting is an invariable accompaniment, continuing at irregu- 
lar intervals until the obstruction is relieved or until the child dies. 

The exanthemata and lobar pneumonia are very commonly ushered 
in by vomiting if the onset is sudden and intense. In appendicitis 
in children, vomiting is usually one of the early symptoms; so also, in 
the different forms of meningitis, vomiting is often an early symptom, 
and may continue persistently during the first few days of the illness. 
In nephritis, with uremia, vomiting is usually present. Vomiting may 
be caused by fright, by shock, or by a strain of any nature, as in whoop- 
ing-cough, or it may be of purely nervous origin. 

Illustrative Case.— A few years ago I had a most unusual and interesting case. 
The patient was a girl four years old, pale and thin. The history was that of 
vomiting for more than a year, which had begun with rather a protracted, badly 
managed attack of indigestion. At first there were but one or two attacks a day. 
Later they became more frequent, and for a few weeks before the child came to 
me the vomiting had occurred at the table with nearly every meal, before the meal 
was completed. The mother was most anxious and apprehensive regarding the 
child's condition. The former was always with the patient, always fed her, and 
always worried constantly throughout the meal, fearing an attack of vomiting. 
Using the most thorough means of examination of the stomach, I failed to find 
anything wrong with it. After some days' observation it occurred to me that the 
presence of the apprehensive mother, in whose mind the condition of the child and 
the vomiting were uppermost, might be a factor in causing the vomiting. ^ I 
accordingly directed that the child take her meals in the kitchen with the maid. 



220 THE PRACTICE OF PEDIATRICS 

and that the matter of vomiting should not be mentioned. The mother was 
directed not to come in contact with the child in any way during the meal. I was 
much gratified and not a little surprised when the vomiting promptly ceased. 
After a few months of this regime the maid was taken ill, and the mother for one 
day attended to the feeding. Again the child vomited as before. 

The management of the different types of vomiting will be 
referred to in the consideration of the various diseases with which it is 
associated. 

RUMINATION 

Rumination is a rather infrequent condition and one which is Hkely 
to be overlooked unless one is very careful to watch the vomiting child 
after feedings. It is characterized by the regurgitation of food after 
almost every feeding, part of which is actually vomited and the rest is 
re-swallowed. 

Etiology. — This condition occurs most frequently in children a few 
months of age and is often not diagnosed until the vomiting has been 
going on for several weeks. The condition may also be present in 
older children. When practised at this age it has become a habit and 
occurs especially in the neurotic. In infants there may be an asso- 
ciated pylorospasm. 

Symptoms. — The clinical picture is fairly characteristic, closely 
resembling that of the ruminating animals, such as the ''cow chewing 
the cud." A few minutes after the baby gets its bottle, it will start 
peculiar suction movements and presently some of the milk can be 
seen in the mouth, a part may spill out and part will be chewed and 
re-swallowed. This proceeding will be repeated until the child has 
emptied its stomach or fallen asleep. 

These children are often much emaciated from the prolonged loss 
of food. 

Treatment. — A popular method of treatment is to give food so 
thick that it cannot readily be regurgitated. A mixture containing 
l}yi ounces of barley flour to 1 pint of skimmed milk is cooked in a 
double boiler for one hour. On cooling, this forms a thick gelatinous 
mass. It is fed with a spoon to the child in quantities to which he 
is accustomed at intervals of 3 to 4 hours. 

Strauch, of Chicago, has observed that the nostrils had to be 
open to aid the child in regurgitating the food. He therefore im- 
provised a clamp to keep them closed for a certain time after feedings. 
In this way he controlled the vomiting to a great extent. 

In a private patient the habit was broken by substituting another 
habit, less harmful. The ruminating infant was taught to use the 
pacifier. Sucking the pacifier proved more entertaining than 
ruminating. 

Sedgwick advises strapping the lower jaw firmly to the upper by 
means of adhesive plaster, thereby preventing the rhythmical jaw 
action necessary for regurgitation. 

ACUTE ILEOCOLITIS (DYSENTERY) 

In dysentery there is a well-defined infection of the intestine. In 
common with other intestinal disorders it occurs most frequently dur- 



ACUTE ILEOCOLITIS (dYSENTERY) 221 

ing the hot months. The later summer and early autumn supply the 
most cases. In Hke manner it often follows the milder gastro-intestinal 
derangements which are productive of reduced vitality and diminished 
intestinal resistance. 

Bacteriology. — In a large percentage of cases of infantile diarrhea 
associated with blood and mucus in the stools the dysentery bacillus 
is present. It may be found in large numbers, sometimes in almost 
pure cultures. Duval and Bassett, in 1902, were the first to find 
Bacillus dysenterise in the stools of cases of infantile summer diarrhea. 
The type of the bacillus which does not ferment mannite (the Shiga 
type) is not found so often in these cases as are the two mannite-fer- 
menting types: the Flexner-Manilla and the Hiss-Russel, of which the 
former ferments maltose, saccharose, and dextrin, and the latter does 
not. 

The presence of agglutinins in the blood of the patient is evidence 
of the causal relationship of Bacillus dysenteriae to the existing disease. 
The agglutinins are not present, as a rule, until the second week of the 
disease. 

Pathology. — The lower portion of the ileum — rarely more than 
three feet — and the colon are the locations of the lesion which may 
show a wide variation in intensity, depending on the character of the 
infecting organism and the resistance of the patient. While the major 
lesions are usually in the colon, the small intestine will show pathologic 
changes in at least 35 per cent, of the cases. There may be localized 
areas of congestion through the intestine, enlargement of the solitary 
follicles, and swelling of Beyer's patches. In nearly all cases, whether 
the lesions are mild or severe, there will be moderate swelling and con- 
gestion of the mesenteric glands. 

The inflammation may be acute or chronic, and catarrhal, ulcera- 
tive, or pseudomembranous in tj^pe. Although the term, dysentery 
is properly used to denote only infections by the bacilli of Shiga and 
Flexner and the special protozoon, Amoeba coli, the lesions produced 
may be conveniently considered under the term, ileocolitis. 

In a series of 82 autopsies upon cases of ileocolitis Holt found fol- 
licular ulceration predominant in 36, catarrhal inflammation in 26, 
membranous inflammation in 14, and catarrhal inflammation with 
superficial ulceration in 6. Of 412 cases studied by Holt and Flexner 
in 1903, 270 showed the presence of Bacillus dysenteriae, and Flexner 
acid-forming type of organism appearing most frequently. Strains 
intermediate between the Shiga and Flexner bacilli are occasionally 
found, and in the causation of a certain proportion of cases of epidemic 
dysentery Bacillus pyocyaneus has been shown to be active. Amebic 
dysentery is common only in tropical or subtropical regions. 

In simple ileocolitis of the mild catarrhal form the submucosa is but 
slightly involved. The mucosa, however, is swollen, congested, and 
covered with secretion, and dotted with occasional points of hemor- 
rhage and spots of epithelial exfoliation. The lymph-follicles are 
swollen and hypertrophied, and the adjacent connective tissue is in- 



222 THE PRACTICE OF PEDIATRICS 

filtrated with round-cells. Microscopically, this infiltration is also 
apparent about the vessels in the submucosa. The stools are ordi- 
narily green and thin in consistence, and contain mucus, desquamated 
epithehum, and traces of blood. In severe cases the inflammation 
acquires the ulcerative or membranous character, the lymphoid follicles 
are elevated and superficially necrotic, and the submucosa is infiltrated 
with pus. In such instances the ulcerations extend deeply, and ex- 
ceptionally involve the entire intestinal wall. 

The Ulcerative Form. — In ulcerative ileocolitis the ulcers may origi- 
nate in the solitary follicles, and are then small, superficial, round, 
yellow, sharply defined, and surrounded by an inflammatory zone. 
Later the ulcers may grow larger, coalesce, and become deeper, exposing: 
the submucosa or even the muscularis. Ulcers may also originate in 
the mucosa itself and not in the follicles; this may occur in dysentery 
or in cases of severe catarrhal inflammation. As a consequence of 
the coalescence of these ulcers the mucosa has a ragged appearance, 
with islands of gray or congested mucous membrane visible between 
the irregularly shaped ulcers of all sizes. Small ulcers heal completely, 
but large ones rarely do. Stenoses as the result of cicatrization of these 
ulcers do not occur in children. In cases of long standing all the in- 
testinal coats are thickened, due to inflammatory infiltration, and the 
mucosa becomes pigmented. 

In pseudomembranous ileocolitis the intestinal mucosa is covered 
with a fibrinous exudate, which can be rubbed off at first, but later is 
very adherent. The mucosa becomes necrotic, and larger or smaller 
areas are lost, leaving a congested, edematous base, surrounded by 
necrotic tissue. The pseudomembrane becomes colored yellow or 
greenish by the feces. The wall as a whole is thickened. The lesion is 
usually most marked in the colon, but the lower ileum is often involved 
as well. Healing may occur, but is rare; death is the rule. 

Associated Lesions. — In severe cases of ileocolitis the mesenteric 
lymph-glands are Involved and the spleen may be enlarged. Perfora- 
tion of the bowel, abscess of the liver, nephritis, and broncho-pneu- 
monia are occasional complications. 

Symptoms. — A great deal of confusion has been occasioned by 
attempts at a nomenclature of the acute inflammatory diseases of the 
intestine which shall make the clinical aspect of the cases fit the patho- 
logic findings. Differentiation, antemortem, into catarrhal, follicular, 
and ulcerative types is impossible, as has been proved by the care and 
daily observation in institution and hospital work of cases that have 
later come to autopsy. 

Consider briefly, for illustration, the gravest cases — cases which 
at autopsy show most extensive ulceration of the intestine. In many 
of these there has been a low temperature, — from 100°F. to 102°F., — 
and the stools have never contained a particle of blood. In others in 
which perhaps considerable blood has been passed for several days, 
there is but a mild congestion of the mucous membrane of the large 
intestine. In still other cases which continue for a considerable time. 



ACUTE ILEOCOLITIS (dYSENTERY) 223 

— from two to three weeks, — with moderate temperature, death 
results from exhaustion, and autopsy shows nothing but an enlarge- 
ment of the solitary follicles, with areas of congestion in the lower por- 
tion of the small intestine. 

Acute ileocolitis may be the primary intestinal disease. In this 
condition the temperature is usually considerably elevated at the 
commencement of the illness — 103° to 104°F. After an evacuation 
of two or three undigested stools the passages consist of light-colored 
mucus, often streaked with blood, or they are of green mucus and 
streaked with blood. In some cases there is a considerable hemorrhage. 
Relaxation of the sphincter and prolapse of the rectum are not at all 
unusual. The passages are small, frequent, and attended with con- 
siderable pain and tenesmus. I have repeatedly seen from 20 to 30 
such passages from one patient in twenty-four hours. 

Far more frequently, however, this condition follows acute gastro- 
enteric indigestion or an intestinal infection, the dangers of which have 
not been appreciated, and which, in consequence has been improperly 
treated. The lesions produced are due to the bacteria and their toxins, 
which have abundant opportunity to produce pathological changes in 
the intestinal mucous membrane, the extent of which can only be con- 
jectured during life. 

An important feature of some of these cases is that an extreme 
degree of toxemia, with resulting prostration, may be present, with 
little fever and insignificant bowel symptoms. In other cases the 
bowel manifestations are very active and the toxemia is slight. The 
active cases offer the better prognosis. Vomiting may be present at the 
onset of the attack, but is not usually a symptom of consequence. 
There is always emaciation. The degree of prostration is dependent 
upon the amount of toxemia, the extent of the lesion, and the manage- 
ment of the case, particularly as relates to supportive measures and 
the nature of the nutrition. 

Duration. — The duration of an ileocolitis is longer than that of any 
of the intestinal disorders previously mentioned. With the disease 
established it is rare for a case to recover under ten days. The duration 
of the illness is often two or three weeks. I have repeatedly known 
cases to continue over four weeks. In fact, the duration in many in- 
stances is similar to that of typhoid fever. The temperature range is 
variable — from normal to 104°F. For three or four weeks in a given 
case there may be a low temperature range — 99.5° to 101.5° or 102°F. 

Treatment. — Recent work in the bacteriology of the acute intestinal 
diseases has added nothing to our knowledge as to the treatment of the 
condition, and consequently does not call for discussion here. Milk 
is to be stopped at once, whether the patient is breast-fed or bottle-fed. 
Barley-water, granum-water, or rice-water No. 1 (see formulary, p. 
70) constitutes the basis of diet for children under one year of age. 
Older children may be given the No. 2 mixture. To these carbo- 
hydrate foods may be added an ounce of chicken or mutton broth, with 
salt or sugar to make them more palatable. It is well, for variety, to 



224 THE PRACTICE OF PEDIATRICS 

make up two or three cereal preparations and alternate their use. In 
this way the foods will be better taken and for longer periods than if 
but one is prepared. In this form of substitute feeding an amount 
similar to what the child was accustomed to in health may be given, 
but the intervals may be shorter by one-half hour or one hour. 

To patients of any age Eiweiss Milch (page 65), two or three 
feedings daily, may be given. It supplies additional nutrition, and if 
the disease is prolonged, there is correspondingly less emaciation. In 
using the Eiweiss Milch it should at first be diluted with barley- 
water — 3^^ milk to ^i water at first, to be increased to H milk and J-^ 
barley-water. 

Drugs. — I have had abundant opportunity to test the value of the 
different drugs advocated from time to time for the treatment of this 
disease. Drugs which have proved of unquestioned value are castor 
oil, subnitrate of bismuth, and opium. Drugs which have an occa- 
sional application are sulphur and the preparations of tannin. Con- 
stitutional measures, supportive in character, such as heat and stimu- 
lation, are, of course, used when indicated, as in any severe exhaustive 
illness. 

At the commencement of the attack two drams of castor oil should 
be given. If this is not retained, from one to two grains of calomel 
should be given in divided doses — 3^ grain every hour. In cases with 
considerable fever and infrequent stools it is well to repeat the oil or 
give some other laxative, such as magnesia, every two or three days. 

Bismuth subnitrate is best given in 10-grain doses, according to the 
suggestions on p. 198. If black stools do not follow its administration, 
one grain of precipitated sulphur is added to each dose. To be effective, 
the bismuth must be given in large doses. Two or three grains at 
intervals of two or three hours are of no value. In cases over one year 
of age 15 to 20 grains are frequently given at two-hour intervals. I 
have used hundreds of pounds of bismuth in children during the past 
twenty-five years, and have yet to see harm resulting from its use. Of 
course, the physician must use a pure article. Not a few cases do 
admirably under the cereal-water diet, castor oil, bismuth, and sulphur. 
Tannalbin, in doses of 2 grains in infants, and from 5 to 8 grains in 
older children, is sometimes of service when there is a tendency to large 
watery stools or stools containing large quantities of mucus. This 
also may be given at the same time as the bismuth. 

When there is much pain and tenesmus, with frequent, scanty, 
mucous stools, opium may be used with advantage, with a view to con- 
trolling the tenesmus and diminishing the frequency of the stools. 
Paregoric or Dover's powder is usually selected for this purpose. 
Dover's powder is preferred, because of the absence of a disagreeable 
taste and the convenience of its administration. It may be added to 
the bismuth at each dose, not combined with it in a prescription, for 
uncombined it may be at once discontinued or given in smaller doses 
with a diminution in the number of the stools. 

Careful instructions should be given when prescribing opium. It 



ACUTE ILEOCOLITIS (dYSENTERy) 225 

is to be given for a definite purpose — to prevent straining and the fre- 
quent passages due to excessive peristalsis. As in the treatment of 
acute intestinal infection, particularly if there is temperature, it is not 
well to attempt to reduce the number of the stools below four or five in 
twenty-four hours, and, of course, opium is not to be given at all unless 
the stools are very frequent. The amount of opium that will be required 
in a given case may readily be determined by carefully watching the 
character and frequency of the stools. For children under one year of 
age the dosage of Dover's powder is from }i to 3-^ grain at two-hour 
intervals, not more than 7 doses being given in twenty-four hours. 
From the first to the tenth year the dose ranges from 3^^ grain to 2 
grains. Mothers and nurses should be instructed that when there is a 
rise in the temperature, or when the child becomes drowsy after its 
use, the opium is to be discontinued, or the dose reduced one-half — 
another advantage of giving it independently. The younger the child, 
the greater caution to be observed in its use. 

When heart stimulants are necessary, the tincture of strophanthus 
is usually selected. Digitalis is not well borne by the stomach ; and for 
the same reason, as well as because of its unfavorable effect upon the 
kidneys, alcohol should be given with caution. When used, alcohol 
should be well diluted and given onh^ temporarily — during the urgent 
period of acute toxemia. Its prolonged use invariably interferes with 
the stomach function. 

Caffein sodium salicylate, in J^- to 1-grain doses at two-hour inter- 
vals, and atropin, Ho 00 "to Moo grain at four-hour intervals, are par- 
ticularly useful in the asthenic cases. For threatened collapse cam- 
phor, 1 to 2 grains hypodermatically in oil, answers well but requires 
frequent repetition at one- to two-hour intervals. Adrenalin 1 : 1000 
in 2 to 5 drop doses, by stomach or hypodermatically, is also of much 
service in collapse. 

Hot Applications. — Hot stupes or hot compresses to the abdomen 
are often most grateful to the patient when there is abdominal pain 
and tenesmus. The hot applications should be changed every fifteen 
or twenty minutes, never being allowed to become cold. 

Colon irrigation should be used at least once in every case of colitis, 
normal salt solution being employed at 100° to 105°F. The solution 
should always be used warm, as it has a pronounced sedative effect in 
some patients when used in this way, and thus may fulfil two purposes. 
Whether the irrigation is repeated or not must depend upon its effect 
upon the patient. When he strains against it and there is no apparent 
diminution in the number of the stools, it should not be repeated. 
Frequently, however, the intestine remains quiet and the number of 
passages is diminished after a warm irrigation — 105° to 110°F. In 
such cases it may be repeated twice daily. In cases in which there is 
not an active bowel action, and decomposing blood and mucus are re- 
moved by the washing, it may be used once or twice daily. 

Only in the rarest instances, when there is high fever and bowel 
action is delayed, should intestinal irrigation be practised oftener than 
15 



226 THE PRACTICE OF PEDIATRICS 

once in twelve hours. This Hne of treatment is often overdone. Irri- 
gation should always be used for a definite purpose, and discontinued 
when that purpose is accomplished. Every year, at the close of the 
heated term, I see cases of chronic colitis without fever which are being 
treated by irrigations two or three times daily without any indication 
for the irrigation other than the mucous stools. Irrigations, without 
question, help to keep up the secretion of mucus, for I have repeatedly 
seen it disappear entirely in a few days without other treatment after 
the discontinuance of the irrigation. When irrigation is practised fre- 
quently in those with inactive peristalsis, it is possible to produce a 
general edema due to the absorption of the fluid. This has been done 
experimentally in well children. 

Starch and Opium. — The time-honored remedy — the injection of 
starch and opium — may be of service in the cases in which there is 
much tenesmus, with the passage of small amounts of blood-streaked 
mucus or the discharge of bloody mucus from the rectum. In these 
cases the principal lesions are usually located in the sigmoid and 
rectum. A straight-pipe, hard-rubber syringe answers best for this 
purpose. A starch solution of the strength of 1 dram of starch to 1 
ounce of boiled water is used. For infants under one year of age 5 
drops of laudanum may be added to 2 ounces of the starch solution, 
and repeated at intervals of six to eight hours. Older children may be 
given from 8 to 12 drops of laudanum with 4 ounces of the starch 
solution; this may be repeated in four to six hours. 

Improvement in the colitis is indicated by a subsidence of the 
temperature, a change in the character of the stools from green or clear 
mucus, with blood and scarcely any odor, to passages which gradually 
take on a fecal odor and show the presence of feces mixed with mucus. 

The Influence of Climate.— When the case is under control, a change 
of climate is most beneficial. A child who has had colitis at the sea- 
shore or in town will invariably have recovery hastened by a removal 
inland to the mountains or among the hills, where an open-air life is 
to be insisted upon. 

Diet in Convalescence. — With a subsidence of the fever and an im- 
provement in the number and character of the stools the patient's 
troubles are not over. The problem of nutrition is often a difficult 
one. The child has necessarily been on a reduced diet for several days 
— often for two to three weeks. If better nutrition than cereal gruels 
and Eiweiss Milch is not soon forthcoming, the patient faces the danger 
of malnutrition and marasmus, which is the outcome in not a few of 
the badly treated cases in which the disease is not quickly fatal. The 
use of fresh milk must sooner or later be attempted. 

In all these cases the child has not been getting sufficient caloric 
units for maintenance of weight. This applies particularly to children, 
who, on account of age or refusal to take it or intolerance, have not had 
the benefits of Eiweiss Milch. 

Children who have had colitis bear fat badly. The younger the 
child, the more certainly is this the case. This has been so forcibly 



CHRONIC ILEOCOLITIS 227 

impressed upon me that I have discontinued attempts at feeding these 
convalescents, even with small quantities of whole milk. I have found 
that they do best on a carbohydrate gruel as a basis of diet, to which 
sugar-of-milk is added in the proportion of from J-^ to 1 ounce to the 
pint, thereby furnishing material for heat and energy. To this sugar- 
cereal combination, boiled skimmed milk in small quantities is added, 
not over 3-^ ounce, and that to only one of the feedings, the first day that 
milk is given. If this causes no inconvenience, an increase of 3^ ounce 
is made at every second feeding the following day, and an increase of 
J'^ ounce at every feeding the third day. The total quantity of food 
given at each feeding is to remain the same, an equal quantity of the 
cereal diluent being removed to make way for the milk increase- 
Thereafter, if all goes well, an increase of 3^ ounce is made in each 
feeding every day until the child is taking his daily feedings of skimmed 
milk one-half strength. In some cases it may be found that the child 's 
capacity will be only 2 ounces of skimmed milk at a feeding with the 
cereal-water diluent. Here he must be held, perhaps, for a week or 
two before milk can safely be advanced. Usually the younger the 
child, the more difficult will be the resumption of the milk diet. After 
the first year the nutrition may be assisted by a thick gruel, such as 
No. 2 (see formulary, p. 70), zwieback, bread-crusts, or rare scraped 
beef — two or three teaspoonfuls daily, with a couple of feedings of 
Eiweiss Milch or buttermilk. By infants under one 3^ear of age who 
cannot take even a weak dilution of skimmed milk, granum No. 1 
(p. 70) will usually be well taken. If there is abdominal distention 
from starch indigestion, the granum may be dextrinized. Barley- 
water also answers well as a diluent for evaporated milk. In adding 
evaporated milk to the cereal water sugar is to be omitted. The evapo- 
rated milk may be increased slowly until from 1 to 4 drams are given 
at a feeding. Under no ordinary considerations, however, should 
this diet be permanent. After from two to four weeks the use of 
plain milk should be attempted, replacing one feeding of the evapo- 
rated by a small amount of plain milk — J^ to 1 ounce is the customary 
diluent. 

Obstinate constipation sometimes follows recovery from severe 
ileocolitis. This is to be managed along the lines laid down for the 
management of constipation (p. 244). Following an attack of ileoco- 
litis the patient must never be allowed to pass twenty-four hours 
without an evacuation of the bowels. A standing order should be 
given that an enema should be used when this does not occur. 

CHRONIC ILEOCOLITIS 

Cases of chronic ileocolitis coming under my care have invariably 
been preceded by acute attacks that were unusually severe or that were 
badly managed. These cases represent one of the forms of malnutri- 
tion, but are of such a nature as to require special consideration. 

The walls of the intestines are thickened with connective-tissue for- 



228 THE PRACTICE OF PEDIATRICS 

mation, and the solitary follicles have undergone pigmentation as a 
result of hemorrhages or congestion. 

SymptomSc — The patient is emaciated, and often three or four 
pounds under weight; the skin is dry and rough; the circulation is poor; 
the extremities are cold, and the temperature is often subnormal, show- 
ing an occasional sharp rise. The abdomen is always distended with 
gas. The stools usually are loose, number three or four daily, and con- 
tain mucus in considerable amount. The mucus may be absent for 
two or three days; then there will be a rise in temperature of from 
102°F. to 105°F., and large quantities will be passed with a very foul 
odor. The nervous symptoms are usually marked. The child is 
irritable and sleeps poorly. He cries a great deal, is very unhappy, 
and looks as wretched as he apparently feels. 

In assuming the care of one of these cases it is well to inform the 
parents that a rapid improvement is not to be looked for. A patient 
aged three and one-half years, who eventually recovered, weighed but 
23 pounds — 2 pounds less than when she was eighteen months old. 
During the first six months that I treated her there was very slow im- 
provement in spite of every advantage that care and change of climate 
could afford. 

Treatment. — The management consists in a proper diet, change of 
climate when possible, and supportive measures. It is for the physician 
to find out in a given case what means of nutrition are best. These 
cases vary considerably in their digestive possibilities, with the excep- 
tion that they all bear fat foods badly. 

Diet — Chronic colitis is very fatal in young infants, and but few 
survive. By far the best food for infants under one year of age is 
breast-milk, which at first must be given in small quantities. Sugar- 
water should be given before the nursing. These young infants do not 
do well on starchy foods unless they have been dextrinized (p. 71); 
when predigested, they may have too laxative an effect, and should 
be given in small quantities. The use of starch, therefore, in these 
cases, for a considerable time at least, is limited. 

Eiweiss Milch and buttermilk have failed me absolutely in feeding 
these young children. The patient may be able to digest the unsweet- 
ened condensed milk in the proportion of 1:6 or 12 of water or weak 
gruel diluents. Two or three feedings a day may be given in alterna- 
tion with a dextrinized gruel. The addition of ^i ounce of gelatin to 
the pint of food makes a desirable addition to the feeding of malnutri- 
tion cases in which food of low caloric value is necessary. 

The beaten white of egg may be given in diluted skimmed milk or 
in dextrinized gruel No. 3 (p. 70) if it agrees, or in plain water with salt 
added. The whites of two or three eggs may thus be given daily 
with benefit. For older children, after the first year, skimmed milk, 
Eiweiss Milch, rare scraped meat, junket, and coddled white of egg 
or raw egg are usually best. Zwieback or bread-crusts may be given in 
small quantities. Alcohol, if given at all, should not be long continued. 
I usually feed these patients five times a day, at four-hour intervals. 



MUCOUS COLITIS 229 

There should be a standing order for an enema after an interval 
of twenty-four hours if no movement from the bowel takes place dur- 
ing that time. Absence of bowel movement in these cases almost in- 
variably is followed by fever, prostration, and perhaps convulsions. 
If there is a tendency to constipation, as there will be in some cases, 
some laxative, such as magnesia or the aromatic fluidextract of cascara, 
should be given daily in sufficient amount to insure at least one free 
evacuation. 

Irrigation of the colon is not be to used as a routine measure. It is 
indicated whenever there is a rise in temperature, even though the 
bowels have moved but a few hours previously. A laxative, prefer- 
ably castor oil or calomel, should also be given. 

The further treatment calls for salt baths, oil inunctions, and the 
open-air life referred to in the section on Malnutrition, p. 92. 

MUCOUS COLITIS 

Mucous colitis is a chronic catarrhal condition of the colon, char- 
acterized by the production of very large quantities of mucus. The 
mucus forms a pseudomembrane over the mucosa, and is passed in 
the form of casts or large, worm-like masses. 

Attention has elsewhere been called to the necessity, in dealing with 
some of the diseases of children, of ignoring what appears to be a local 
manifestation of disease, and treating the patient along dietetic and 
hygienic lines. This necessity is in no instance better illustrated than 
in mucous colitis, a disease fortunately rare in children, yet of sufficient 
frequency to warrant our attention. 

Etiology. — The patients who have come under my care have in- 
variably been of a pronounced neurotic type, usually of neurotic ances- 
try, and invariably from a neuropathic environment. It is quite 
usual to find that a considerable quantity of milk has been taken daily. 
Ptosis of the transverse colon and the elongated or ptosed sigmoid 
(p. 208) may be in part responsible for some of these cases. 

Symptoms. — The disease rarely follows an acute inflammatory proc- 
ess in the intestine. In the majority of instances there is a history 
of obstinate constipation in a markedly neurotic, underfed child. Con- 
stipation may have existed during the patient's entire life. Almost 
without exception the treatment which has been followed has consisted 
in the use of colon irrigations and various kinds of astringents, such 
as solutions of tannic acid, nitrate of silver, etc. In children with 
mucous colitis the appetite is capricious, the bowels are usually consti- 
pated, and the disposition is chronically irritable. These children are 
apt to complain of ill-defined pains in the abdomen, which are never 
very severe and are not necessarily associated with the taking of food. 
There is usually slight generalized abdominal pain on pressure. A child 
four years of age, under treatment at the present time, — the most pro- 
nounced case that I have ever had under my care, — has never had the 
sHghtest evidence of pain of any character. With the dejections there 
is usually mucus in considerable amount, which is occasionally passed 



230 THE PRACTICE OF PEDIATRICS 

in large masses, at other times in long, tenacious strings, sometimes re- 
ferred to as '' ropy." During a period of several consecutive days little 
or no mucus may be passed; then large amounts will suddenly appear. 

Treatment. — These cases respond most quickly when local measures 
which often act as irritants to the intestinal mucous membrane are 
discarded. Usually, as a result of previous treatment and because 
of the nature of the disease, the constipation is most obstinate. To 
prevent this I use an injection of two to three ounces of olive oil at 
bed-time, the tube being i^itroduced 8 inches into the bowel. 
After breakfast on the following morning the child is placed at stool, 
and if no passage occurs within fifteen minutes, a glycerin supposi- 
tory is inserted. By this means one passage daily is insured, and 
this, ordinarily, is all that is required. The use of the suppository 
is to be discontinued after a very few days, as soon as the habit of 
evacuation at a certain time is established. Should this method fail, 
from one to two drams of the aromatic fluid extract of cascara may 
be given in addition, at bedtime, this medication being gradually di- 
minished and discontinued as soon as it is demonstrated that an evacua- 
tion will occur without medicine. A remedy of considerable value is 
the liquid albolene (aromatic), given in dosage of J^ ounce to 2 ounces 
at bedtime, and continued in gradually diminishing doses until the 
stools are free. Local measures other than those suggested for consti- 
pation are not to be employed. 

Diet. — Not infrequently these patients have been taking a consider- 
able amount of milk. This is immediately discontinued. In its place 
malted milk or whey is given. The further diet consists of whole- 
wheat bread, animal broths, cereals cooked three hours, eggs, poultry, 
red meat, stewed fruit, and fruit-juices. Spinach, stewed carrots, 
and asparagus-tips are the only vegetables allowed at the beginning 
of the treatment, and these by no means should always be given. Pur^e 
of peas, beans, and lentils may be given freely. The use of butter is 
also encouraged. I endeavor to have the patient take three ounces 
daily. It may be given on bread or on the cereal. 

Drugs. — Strychnin and nux vomica appear to exert a very bene- 
ficial influence on these cases. The combination of nux vomica and 
quinin has been very satisfactory. For a child from five to ten 
years of age the following should be ordered: 

I^ Tincturse nucis vomicae gtt. xc 

Quininse bisulphatis gr. Ix 

M. div. et ft. capsulse No. xxx. 
Sig. — One capsule after each meal. 

A child suffering from mucous colitis invariably shows a considerable 

degree of malnutrition. For details respecting sleep, rest, exercise, 

and baths, all of which are more important than medication, the reader 

is referred to the section on Tardy Malnutrition (p. 100). 

HIRSCHSPRUNG'S DISEASE (IDIOPATHIC DILATATION OF THE 

COLON) 

Two forms of Hirschsprung 's disease are recognized — the congenital 
and the acquired. 



THE INTESTINAL INFANTILISM OF HERTER 



231 



The condition is rarely encountered — probably not over 100 cases 
are to be found in the literature. Only two well-marked cases have 
come under my observation. Theje is an enormous dilatation and 
hypertrophy of the colon without constriction. The greatest dilatation 
is found in the transverse and descending colon. In the cases described 
by Hirschsprung there were ulcerative processes in the mucous mem- 
brane and submucous abscesses. 

Etiology. — In all cases the condition is \^ ~ ;^si:s*^.-*^^-^.-^ 

probably based upon congenital structural 
defects. 

Symptoms. — The prominent symp- 
toms are obstinate constipation, sym- 
metric enlargement of the abdomen (Fig. 
23), and malnutrition. 

The bowels may act only once in three 
to six weeks. Complete obstipation of 
two or three months' duration has been 
reported (Cautley). Respiration is often 
impeded because of pressure on the dia- 
phragm. For a like reason the heart 
action may be interfered with. The 
hepatic and splenic dulness is obliterated. 

Prognosis. — The prognosis for a com- 
plete cure is unfavorable. The patient 
usually succumbs to intercurrent disease. 

Treatment. — Little is to be expected 
from treatment, whether medical or surg- 
ical. Various operative procedures have 
been attempted. The radical operation 
involving complete removal of the colon 
has been performed. As long as it is 
possible to produce an evacuation of the 
colon the patient may remain in a fairly 
comfortable condition. Laxative drugs, 
massage, electricity and colonic irriga- 
tions may all prove useful as temporary 
aids. 




Fig. 23.- 



-Hirschsprung's dis- 
ease. 



THE INTESTINAL INFANTILISM OF HERTER 



Notwithstanding the great amount of scientific work accomplished 
by Christian A. Herter, it seems likely that his name will be per- 
petuated in connection with this condition of intestinal infantilism, 
more than by any other work that he did, for he described a condition 
that was never before carefully studied and thus established it as a 
distinct disease with characteristic symptoms, intestinal flora and 
changes in the urine (Freeman).* 

In this disease there is an arrested physical development, the child 
* Journal A. M. A., vol. ii, p. 329-332. 



232 THE PRACTICE OF PEDIATRICS 

is usually well formed but does not grow and does not gain in weight. 
A patient under treatment at present, — a female, is seven and one-half 
years of age, weighs 20 pounds and is 343-^ inches tall. No growth 
has taken place since she was two years old. 

A description of this child covers the symptomatology in all. The 
mental development is normal, the patient can read and write. In 
addition to the small stature there is a marked enlargement of the abdo- 
men. The patient is of low resistance — she tires readily and is peevish 
and unhappy. She has an enormous appetite and demands food about 
five times a day. The stools are large and fatty in appearance and 
contain a large amount of fat and fatty acids. In Herter's infantilism 
frequent attacks of diarrhea are the rule. The urine shows an excess 
of putrefactive products of intestinal origin, the indican and phenol 
compounds are present. The bacterial flora of the intestinal tract, 
according to Herter,* are gram-positive organisms of the bacillus 
bifidus type, bacillus infantilis type and cocco-bacillary forms. There 
is a marked absence of gram-negative bacilli in the stools. 

Infants of this type are very discouraging patients. No pro- 
nounced improvement is to be expected from any line of treatment. 
Milk, rare meat and poultry, and cereals, such as oatmeal, and the 
wheat derivatives constitute the basis of the diet. 

Freeman feels that he has observed benefit from the use of extract 
of pancreas 3 grains, three times daily in the form of an enteric pill. 

INCONTINENCE OF FECES 

Incontinence of feces is a normal condition during infancy, con- 
trol being established without training during the second year or earlier. 
In well-trained infants I have seen the bowel function under perfect 
control at the third month. This is, however, unusual. With a 
very little teaching it may be accomplished at the sixth month. In- 
continence of feces in older children occurs during acute inflammatory 
conditions, particularly when the colon is the seat of the lesion. In- 
continence may also occur in asthenic states, as in grave pneumonia, 
in typhoid fever, and in severer types of the exanthemata ; and it may 
occur accidentally as the result of fright, shock, or severe straining. 
It may result from spinal cord disease or injury, and is sometimes 
present in spina bifida, in which event the fecal incontinence may be 
compared to incontinence of the urine. I have seen 5 such cases. 
In 2 the condition had existed for months. The desire for an 
evacuation was urgent and without warning, and was uncontrollable. 

Incontinence of feces, as a condition independent of early infancy 
and illness, is of exceedingly unusual occurrence. I have seen but 5 
cases — 2 in boys, one four and the other seven years of age. In these 2 
the condition had persisted for months. The desire for an evacuation 
came with great urgency and was uncontrollable. In 2 other cases 
there was occasional incontinence due to a relaxed sphincter, probably 
* Herter's "Infantilism," Macmillan Co., 1908. 



INTUSSUSCEPTION 233 

produced by frequent irrigations. These responded to the treatment 
outhned below. In the fifth case there was no response to any treat- 
ment instituted. The patient was a boy six and three-quarter years 
of age, and had suffered from the incontinence for a year and two 
months. He was under treatment for two weeks; no improvement 
resulted, and he passed from observation. 

Treatment. — ^The treatment consisted in the removal of green vege- 
tables and fruit from the diet, allowing only a small amount of starches, 
such as bread, potato, and cereals. Eggs, meat, skimmed milk, junket, 
custard, etc., were given freely. The medicine comprised 15 drops of 
the tincture of the muriate of iron in glycerin and water, given every 
four hours, with 1 grain of Dover's powder and 20 grains of subnitrate 
of bismuth (Squibb) given three times daily. Cases which do not re- 
spond promptly to diet and medication should have the advantage of 
surgical procedures. 

INTUSSUSCEPTION 

Intussusception of the bowel consists of a prolapse — an invagination 
— of a portion of the intestine into an immediately adjoining portion. 

Types. — While certain portions of the intestine are particularly 
liable to be involved, the invagination may take place in any portion 
of the gut. Thus the small intestine may be the part involved — the 
enteric form. The colon alone may be involved — the colic type. By 
far the most common form is the prolapse of the cecum, and more or 
less of the ileum into the colon, the valve forming the apex of the tumor. 
This is known as the ileocecal type. 

Invagination Found at Autopsy. — At autopsy it is of most common 
occurrence to find invagination of the small intestine. I have repeat- 
edly seen 6 to 8 invaginations in one subject. They occur at death, and 
are of no significance. It is unusual to find more than 4 or 5 inches of 
the gut involved. 

Etiology. — The cause of the intussusception is unknown in the 
great majority of cases. Various theories have been advanced from 
time to time, none of which deserves mentioning. Occasionally local 
causes will explain the condition. In one of my cases Meckel's diver- 
ticulum caused the intussusception. In another there was a persistent 
incomplete reducible invagination of the transverse and descending 
colon into the sigmoid. It was impossible to keep the parts in the nor- 
mal position, and laparotomy was resorted to in order to learn the cause 
of the prolapse. The entire colon was found displaced, the hepatic 
flexure being bound to the abdominal wall by a firm adhesion one-half 
inch above the umbilicus. This caused a displacement downward of 
the transverse and descending colon, which underwent invagination. 
A case in my service at the Babies' Hospital showed that the invagina- 
tion had taken place at the site of a large and thickened Beyer's patch 
in the lower ileum. Here, evidently, the gut was more resistant, and 
the portion above, during active peristalsis, slipped into the less motile 
section. 



234 THE PRACTICE OF PEDIATRICS 

It is peculiar that nearly all the cases occur in well-nourished, 
vigorous, breast-fed babies. 

Age. — The age incidence is striking. The majority of the cases 
occur between the third and ninth months of life. My youngest pa- 
tient was ten days old. Holt's statistics of 358 collected cases are as 
follows : 



28 cases under 4 months 
113 " from 4 to 6 months 
71 " " 7 to 9 " 



18 cases from 10 to 12 months 
32 " " 1 to 2 years 

96 " " 2 to 10 " 



Symptoms. — The onset is usually sudden, with evidence of pain and 
vomiting. A further early and very important sign is the marked 
prostration, which is much more pronounced than in an ordinary gas- 
tro-enteric disease. The child in a few hours may look very ill. There 
is cyanosis, and the pulse is rapid and small. I have observed this 
symptom-complex in several cases. The vomiting, which is very 
active, is repeated at fairly short intervals, and after the stomach is 
emptied bile-stained mucus is ejected with much straining. Medica- 
tion, food, and water are ejected as soon as they reach the stomach. 
There is evident tenesmus; the child strains, and at first passes normal 
bowel contents, followed by bile-stained mucus, and later clear mucus 
streaked with blood — a most reliable diagnostic sign. Blood is not 
always present. In some instances only white, tenacious mucus is 
passed or removed on the examining finger. On the other hand it 
may be present in large amount, constituting a very definite hemor- 
rhage. The prostration, urgent at the beginning, increases, and the 
patient may die of shock before operation is attempted. 

The Presence of Tumor. — If the case is seen early, a sausage-shaped 
tumor may be felt, or the rounded apex of the tumor may be felt by rec- 
tal examination if the descending colon is involved. If the patient is 
not seen until several hours or days have elapsed, the accumulation of 
gas in the intestines renders th6 palpation of a tumor impossible. 

Occasionally a case is seen in which the onset is more gradual, in 
which gas and bile-stained mucus will be passed for a day or two. This 
indicates that the invagination is not sufficient to close the lumen of the 
gut. Finally, only blood and mucus are passed and the obstruction is 
complete. Three or four days may be required to bring this about. 
Vomiting is a less pronounced symptom in these cases of gradual 
development. 

Stercoraceous vomiting does not occur in young infants. 

The Temperature. — The temperature range is of no significance. 
In many cases the temperature is never above 100°F. 

Diagnosis. — There is no satisfactory excuse for so many failures in 
diagnosing intussusception in. infants. The reason for the failure to 
appreciate the condition is because physicians too readily interpret 
active vomiting, with green mucous and bloody stools, as significant of 
gastro-enteric intoxication. 

Distinguishing features of intussusception are: Vomiting, sudden 
and urgent, in well infants, who may be breast-fed; shock and collapse 



INTUSSUSCEPTION 235 

out of proportion in severity to the other symptoms; the passage of 
clear, mucous stools streaked with blood, together with the presence of 
pain of a paroxysmal nature, the absence of the passage of flatus, and 
the sudden distention of the abdomen. 

The presence of a tumor which can be felt either by abdominal pal- 
pation or in the rectum occurs in perhaps 80 per cent, of the cases. In 
cases of ileocecal intussusception the tumor may be difficult to map 
out, particularly if there is much distention of the abdomen. Under 
these circumstances anesthesia should be used in suspicious cases. 
Rectal examination is always a valuable aid and should never be 
neglected. 

Prognosis.^ — The prognosis in the immediate, complete case depends 
largely upon the time of making the diagnosis and the promptness of 
operative procedures. The chance for recovery from operation de- 
creases rapidly with each succeeding day. 

It is impossible to give statistics of value. It is safe to say that 
over 50 per cent, of these cases are curable by some means if they are 
diagnosed early. The high mortality — 50 to 80 per cent. — is due to 
two conditions: the tender age of the patients and the fact that the 
cases seen in consultation and those seen in children's hospitals usually 
have been treated for something other than intussusception. Some- 
times such treatment has been continued for several days. By the time 
those cases reach the hands of the surgeon there may be extensive ad- 
hesions, gangrene of the involved portion of the intestine, and an 
exhausted child to deal with. 

Treatment. — Reduction by Water-pressure. — It is my custom, in any 
case, first to send for the surgeon and then make one attempt at reduc- 
tion by water-pressure: A well-oiled catheter. No. 18 American, or a 
small rectal tube, is attached to the small hard-rubber tip of a fountain- 
syringe. Two quarts of a normal salt solution are placed in the bag, 
which is hung at an elevation of four feet above the child's body. The 
colon, or that part of it below the intussusception, is slowly filled with 
the warm salt solution. A small wet towel is tightly wrapped around 
the catheter, and fairly strong pressure is made at the anus by an 
assistant, in order to prevent the escape of the fluid. With the child on 
his back with both hands free, the buttocks are elevated on a pillow or 
bed-pan at a plane 10 inches above the shoulders. In the cases in which 
the tumoris palpable, an attempt is made, by gentle abdominal manipu- 
lation, to reduce the intussusception. This in two cases I have thus 
succeeded in doing. Prolonged and repeated attempts at reduction 
should not be practised. An early operation gives the child a far 
better chance of life than does any temporizing measure. 

Illustrative Cases. — Case 1. — A child, two and one-half years of age, was brought 
to my office at midnight with a history of a severe attack of colic about 9 o'clock, 
which was followed by severe attacks of vomiting and two stools of mucus and 
blood. Gentle manipulation of the abdomen showed a large, sausage-shaped 
tumor, about five inches long, in the left hypochondrium, which I diagnosed as an 
intussusception. The tumor could not be felt by rectal examination. Water- 
pressure, as described above, with abdominal manipulation, reduced the intus- 
susception in a few minutes. 



236 THE PRACTICE OF PEDIATRICS 

Case 2. — The other patient was a baby nine months of age. I saw the child in 
consultation after the intussusception had existed for six days. The child was 
unconscious and in profound collapse. He was pulseless, but the heart-sounds 
could be faintly distinguished by the aid of stethoscope. The rectal temperature 
was 96°F. The abdomen was greatly distended. The child had been treated for 
cholera infantum, although for five days nothing but white mucus tinged with 
blood had been passed. Palpation revealed a sausage-shaped tumor extending 
along the entire left side of the abdomen, which, in spite of the abdominal disten- 
tion, could easily be made out by firm pressure. The child was unconscious, so 
that there was no resistance to the examination. By rectal examination the pro- 
jection of the involuted gut, which resembled the cervix uteri, could readily be 
distinguished. The condition of the child precluded all chance of surgical relief, 
and I hesitated to use water-pressure, fearing that the gut might be gangrenous 
and a rupture result, or that there might be adhesions sufficient to prevent reduc- 
tion, and that the child might die during the manipulations. I explained the 
situation to the parents, who, after considerable urging, consented to a trial being 
made. The patient was accordingly given Hoo grain of strychnin, 1 drop of tinc- 
ture of strophanthus, and 30 drops of brandy hypodermically. The water- 
pressure was applied in the usual way, and it was with the greatest surprise and 
with supreme satisfaction that I felt the tumor slowly give way, to be followed by 
an expulsion of gas and a quantity of very fetid fecal matter. A hot colon flushing 
at 110°F. with a normal salt solution was given a few minutes later. This was all 
retained, and six hours later 12 ounces more were given. Hot-water bottles and 
bags were placed about the child. He had sufficiently revived in an hour after 
the first colon flushing to be able to swallow diluted brandy and egg-water, both 
of which were freely given. A rapid recovery followed. 

This case, to me, was interesting in many ways, particularly as it emphasized 
what we sometimes see in work among children when victory is snatched from the 
jaws of evident defeat — that we should never cease our efforts so long as life lasts. 

It is my practice to make but one attempt at reduction by water- 
pressure. When this does not succeed after a five-minute trial, imme- 
diate operation gives the patient his only chance of recovery. 

CONSTIPATION 

Constipation in the young has in many instances been ascribed to 
the influence of heredity. It is undoubtedly true that a predisposition 
to deficient musculature in the bowel not infrequently exists apart from 
other assignable cause. In most cases, however, muscular impairment 
and atony of the intestine are induced by prolonged improper feeding, 
constitutional diseases (such as rickets) resulting in deficient general 
nutrition, or artificial assumption of the normal work of the intestine 
by the too frequent administration of enemata or suppositories. 

Deficient fat content in the milk of young infants, and insufficient 
solid food in the diet of children over one year of age, probably are 
responsible for a majority of the cases. The digestive organs demand 
not only elements for assimilation, but a certain amount of food residue 
to act as a stimulus to perfectly normal musculature. The results of 
the absence of a fair amount of this food residue in the diet are most 
apparent in children between the first and third years, who receive 
over a quart of milk daily, administered in frequent instalments, and 
from force of parental habit or perverted desire on their own part are 
deprived of such important dietetic ingredients as cereals, vegetables, 
and fruit. Such children are almost invariably sufferers from chronic 
constipation. 



CONSTIPATION 237 

The cases commonly ascribed to deficient secretion on the part of 
the intestinal glands and liver are also frequently of dietetic origin. 

Mechanical defects and abnormalities may be entirely responsible 
for the most obstinate constipation. Localized proctitis, fissures and 
hemorrhoids, and sphincter-spasm may be important causative factors. 
Congenital narrowing of the gut, elongated sigmoid (Fig. 19), prolapse 
of the colon (Fig. 20), hernia, and congenital dilatation of the 
colon (Hirschspring^s disease) deserve to be borne in mind in this 
connection. 

Before instituting treatment of any nature it is necessary to know 
that no mechanical cause exists. 

Bowel Evacuation Necessary. — In order to keep the infant or 
young child in good physical condition, one free evacuation of the 
bowels is required once in twenty-four hours. While two or three 
evacuations daily in a nursing or bottle baby may be desirable, this 
number is not absolutely necessary. When there are more than four 
passages in twenty-four hours, it means that something is wrong with 
the intestinal tract. This, however, may not be of such a nature as to 
require radical means for its correction. Thus, in many nursing babies 
who are supplied with a high-fat breast-milk, there may be several thin 
greenish stools in twenty-four hours, in spite of which condition the 
child thrives satisfactorily. It is well in these cases to attempt to re- 
duce the fat in the breast-milk by measures suggested elsewhere, but by 
no means should the nursing be interdicted if the baby is making a 
reasonable gain in weight. The proof of successful nursing is a thriv- 
ing child, not the character of the stool. The habit of an evacuation at 
a certain time each day is one of the most important preventives of 
constipation in an infant. There is a standing order in every household 
where I have such a patient, to the effect that the child is never put to 
bed for the night unless the bowels have moved during the preceding 
twenty-four hours. Either a simple soap-and-water enema or a small 
glycerin suppository is employed. The enema is preferred, from 4 to 8 
ounces of the soap-water being used. The suppository is used only 
when, for any good reason, the enema is not available. Placing the 
child at stool immediately after the morning bottle is one of the means 
of establishing the habit of an evacuation at a definite time each day. 
The child soon appreciates the reason for this position and acts accord- 
ingly. This practice may be begun when the child is five or six months 
of age. 

Defective Bowel Evacuation. — Defective bowel evacuation in in- 
fants and young children is a form of constipation very apt to be over- 
looked, and for this reason it is put under an independent heading. As 
long as an evacuation takes place daily it is supposed to be sufficient. 
Even though a passage takes place daily and voluntarily, if it is dry 
and comes away in pieces or in hard balls, or is firmly formed without 
the moist surfaces caused by the presence of mucus and water, it is 
practically certain that the evacuation is not complete and that fecal 
matter is retained in the intestine. This type of constipation is often 



238 THE PRACTICE OF PEDIATRICS 

associated with ptosis of the stomach (p. 177). The ptosed stomach 
always empties very slowly and the absorption of the water from the 
intestinal contents is then more complete. This may occur at any age, 
and when the condition persists, there results, oftentimes, an intestinal 
toxemia, with the manifestations referred to under that caption. 
The same methods of treatment are to be followed as suggested for 
constipation at the various ages of infancy and childhood. Usually, 
however, in this type of constipation, dietetic measures are sufficient. 

Constipation in Nurslings. — There are many nursing infants who 
are thriving and well in every respect, except that they are constipated. 
Bowel evacuation is greatly delayed or does not occur without aid. 
Our first step in the management of these cases is to examine into the 
daily life and habits of the mother. A factor in the etiology of con- 
stipation in the infant is constipation in the mother. Treatment of 
the mother will often relieve the child. If, however, the constipation 
in the mother is not relieved, the subsequent treatment directed toward 
the child will be much less effective. Nursing women who drink a 
great deal of tea are apt to be constipated, and their infants are similarly 
affected. The nurslings of mothers who lead indolent lives, taking but 
little exercise, are likewise sufferers from constipation. 

Treatment of the Mother. — Errors in the mother's diet and habits 
of life must be corrected and the scheme carried out which is recom- 
mended under Maternal Nursing. 

When a proper regime for the mother has been established, the 
breast-milk should be examined. While high proteid may contribute 
to constipation, this factor, in my observation, is rarely a cause. 
Low fat, from 1.5 to 2.5 per cent., with normal proteid is much oftener 
found to be present. 

Often in such cases the fat in the mother's milk may be increased 
by the use of some form of alcohol, given with the meals. Wine, beer, 
ale, porter, or the liquid malt preparations may be given, the mother 
being allowed to make her own selection according to her taste. The 
free eating of red meats also increases the fat in the milk. 

Several years ago a series of observations were made in the New 
York Infant Asylum relating to the effects of diet on breast-milk. 
It was found that in some cases the fat could be increased from 1 to 
2 per cent, by the addition of alcohol to the mother's diet. The value 
of the various galactagogues on the market depends, in all probability, 
upon the alcohol which they contain. 

Treatment of the Child. — A very tight sphincter is the cause of con- 
stipation in a small proportion of nurslings; and before beginning 
other treatment in such cases the sphincter should be stretched by 
passing a protected index-finger into the rectum. As an aid to nutrition 
and as a laxative, a valuable addition to the diet of the constipated 
breast-fed infant, when the mother's milk is found weak in fat, is cow's- 
milk cream, }i to 1 teaspoonful of which may be given before every 
second nursing or before every nursing, according to the age of the 
child and the capacity for fat digestion. Children during the early 



CONSTIPATION 239 

months of life take pure cod-liver oil readily, and oil, like cream, may 
serve the double function of a food and a laxative. Establishing by 
careful instruction the habit of an evacuation of the bowels at a certain 
time every day, is a valuable measure. 

Drugs. — Drug-giving is rarely necessary in treating young children 
and should be resorted to only when other measures fail. In case 
drugs are necessary, those most useful ordinarily are the preparations of 
cascara sagrada. The aromatic fluidextract (Parke, Davis & Co.) 
is palatable and may be given in sufl&cient doses to be effective once 
or twice daily. The milk of magnesia with equal parts of the aromatic 
sjn'up of rhubarb, given in doses of from 1 to 3 teaspoonfuls daily, is 
an agreeable and usually an effective combination. The liquid albo- 
lene (aromatic), in 1 to 4 dram doses, acting as a lubricant, often gives 
surprisingly good results. 

Enemata and Suppositories. — The use of water enemata and sup- 
positories is not to be advised as a routine measure. The habit of 
depending upon them is readily established, the bowel, by their fre- 
quent use, becomes insensitive to stimulation, and in a few weeks they 
fail to act. I have had many mothers come to me in great distress 
when this stage was reached. When the stool is dry and hard and 
is passed with difficulty, the injection of two ounces of warm sweet 
oil at bedtime is of advantage. This is not intended to produce 
an immediate evacuation, but rather to act as a lubricant for the 
evacuation expected the following morning. 

Malted Foods. — It is elsewhere advised that the nursing baby be 
given one bottle-feeding daily. The malted proprietary foods are 
distinctly laxative to many children. It has long been my custom, 
when, in a nursing infant, a condition of constipation exists v\^hich is 
not relieved by careful regulation of the mother's diet, to prescribe 
one feeding of malted milk daily, in the strength of one teaspoonful 
to an ounce of water. Some children will not take malted milk of this 
strength, as the sweet taste is objectionable. In such cases it may 
be given weaker at the beginning, or it may be given in a milk mix- 
ture suitable to the age of the child. When it is used in this way, 
there should be no addition of sugar. Malted milk or Mellin's food 
may be used in a quantity equal of that of the sugar. 

Massage is a most valuable means of treatment in the constipation 
of older children, but in nurslings and in the bottle-fed of tender age, 
on account of the restlessness and crying, is not always practic- 
able, and to be effective it should be given only by those skilled in 
its use; therefore, unless the case is an extreme one, and all other 
measures have failed, massage is not to be employed in the very 
young. 

Constipation in the Bottle-fed. — Before undertaking the treatment 
of constipation in any infant the rectum should be examined to 
determine the presence or absence of sphincter spasm (p. 238). In the 
bottle-fed, inactivity of the bowel is more easily managed than in the 
nurslings, because, in dealing with the former, we are in a better position 



240 THE PRACTICE OF PEDIATRICS 

to adapt the food to the child's digestive pecuUarities. As a rule, 
constipated bottle babies should have a reasonably high fat — 3.5 to 4 
per cent. — and sugar up to at least 7 per cent. This rule, however, 
is open to exceptions ; a few of the most obstinate cases of constipation 
that have come under my care have been fed on a very high fat, 
the constipation being due to fat indigestion. It is extremely rare to 
find a child who can digest, day after day, a milk mixture containing 
more than 4 per cent, of cow's-milk fat. 

The Proteid. — Cow 's-milk casein, although probably the most fruit- 
ful factor in causing constipation in bottle-fed babies, nevertheless, is 
necessary for the child's nutrition. A considerable reduction, such 
as may be obtained by giving a mixture of cream, sugar, and water, 
may relieve the constipation, but the child thus fed will suffer from 
a nutritional standpoint, and instead of being constipated will be- 
come rachitic, which is much worse. In not a few instances I have 
seen malnutrition result from cutting down the proteid in the effort 
to relieve constipation. 

The child's growth and development must never be held subservi- 
ent to anything else. A child under six months of age will not thrive 
satisfactorily on less than 1 per cent, of proteid as found in cow's milk. 
He is entitled to at least 1.5 per cent., and thrives best when this 
amount is given. The relief of the constipation can in almost every 
instance be accomplished by other means than a too great reduction in 
the casein — the most nutritive element in the infant's food. 

Milk given constipated infants should always be raw, as cooking 
increases its constipating tendency. 

Laxative Agents in the Food. — The simplest means of treating 
constipation in the bottle-fed is by the employment of a laxative agent 
in the food, and when such an agent adds to its nutritive value, it 
serves a double purpose. Instead of water as a diluent, oatmeal- 
water No. 1 (see Formulary) may be employed. The malted proprie- 
tary foods, such as Mellin 's food and malted milk, are laxative to most 
children. Mellin 's food is composed largely of dextrose and maltose, 
which are laxative sugars, and therefore may be used in place of sugar- 
of-milk or cane-sugar in the food mixture, for the purpose of relieving 
constipation. In some instances I substitute a feeding of malted milk 
with from 4 to 8 ounces of water once daily for the regular milk food, 
the quantity and strength depending, of course, upon the age of the 
child. 

Drugs and Local Measures. — Dietetic measures should always be 
tried before drugs are resorted to. One or two teaspoonfuls of milk of 
magnesia in one bottle daily may be recommended as a temporary 
expedient in some cases. The magnesia may be of service until the 
condition is controlled by the diet. The aromatic fluidextract of 
cascara sagrada, in doses of from 15 drops to one dram, may be tried 
if success does not follow the use of the magnesia. 

Water enemata and suppositories should be used only as tem- 
porary measures. Orange-juice, 2 teaspoonfuls twice daily before 



CONSTIPATION 241 

feedings, is worthy of trial, and is of antiscorbutic value for children 
artifically fed. Sweet oil and the pure cod-liver oil may be also used 
in doses from 30 drops to 2 drams, three times daily, after feedings. 
Oils produce beneficial effects not only as laxatives, but also as aids to 
nutrition. Acting purely as a lubricant, liquid albolene (aromatic) 
in dosage of 2 drams to J^ ounce, once daily after the evening meal, is 
of much service in many cases. 

Oil Injections. — In case the stool remains hard and dry in spite 
of the above suggestions, an injection of 2 ounces of warm sweet oil 
may be given at bedtime every night, not with a view to inducing a 
passage at the time, but as a lubricant to the parts and as a solvent 
of the hard fecal masses. 

Constipation in Older Children. — Etiology. — Probably the most 
potent dietetic factor in causing constipation in children of the "run- 
about" age is the use of full milk, crackers, and dry bread-stuffs. 
Particularly is this apt to be the case if the milk is boiled. Con- 
stipation may also be occasioned by too great concentration of 
the food, insufficient volume being furnished to produce copious 
evacuations. 

Local Causes. — In a great majority of children the freer feed- 
ing following weaning from the breast and bottle relieves the ten- 
dency to constipation from which many suffer during the earlier 
months of life. In a small percentage of cases, however, such relief 
is not furnished, and the child will require the attention of a phy- 
sician. In making the physical examination of a case of this nature, 
special care should be directed toward the examination of the rectum, 
in order that local causes, such as fissures, hemorrhoids or sphincter 
spasm may be eliminated. If fissures are present, the child will use 
every effort to prevent a bowel movement. 

Mechanical Obstruction. — Elongation of the sigmoid (p. 208), 
ptosis of the colon and cecum (p. 208), plaj^ a part hitherto unsus- 
pected as the causation of constipation. Recently much light has 
been thrown on many difficult and obstinate cases by the use of the 
Roentgen ray. Mechanics play an immediate role in constipation as 
will be appreciated by referring to Fig. 19. The long sigmoid loop 
is an important feature in constipation. 

Regular Habits. — As a rule, children who are presented for treat- 
ment after the second year have not had the benefit of carefully regu- 
lated habits of life, so that our first step is to correct bad habits that 
may have a bearing on the condition, and to teach good habits. The 
desirability of establishing in the child the habit of a bowel evacuation 
at a certain definite time every day should be impressed upon the 
mother or nurse. In order to bring this about, an attempt should be 
made to induce a movement of the bowels by voluntary effort every 
morning after breakfast. Not a few children are too busy, too active 
in their play, to respond to the call of nature when it comes, and if 
it can be repressed, they say nothing about it. If a certain time of 
the day is selected for the evacuation, and if the child is required to 
16 



242 THE PRACTICE OF PEDIATRICS 

remain at stool until it occurs naturally, or by means of a suppository 
after fifteen minutes have elapsed, much is accomplished by this means 
alone toward establishing the habit. 

Diet. — Ultimately, much may be accomplished in these cases by 
diet. Foods other than milk may now be given, so that a high-proteid 
milk, rich in casein, is not necessary. As it is desirable to con- 
tinue the use of milk at this age, the following combination of top 
milk and water may be used instead of full milk: A quart bottle of 
milk is allowed to stand at a temperature between 40° and 50°F. 
for five hours, after which the top 10 ounces are removed with a 
Chapin dipper. (See Fig. 4, p. 57.) The 10 ounces of top milk are 
mixed with 20 ounces of oatmeal gruel or plain boiled water and given 
as a drink. 

The giving of high-fat mixtures in constipation is sometimes over- 
done even in feeding older children. We seldom find a child five 
years of age who can digest, day after day, a milk or cream mixture 
containing over 4 per cent, of fat. Attacks of acute indigestion and 
faulty nutrition are very apt to result when too high a fat is persistently 
given. In not a few instances I have seen grave malnutrition result 
from an attempt to relieve the constipation by high-fat feeding. It 
must also be remembered that high-fat mixtures, if given to children of 
any age, may produce constipation, with hard, very light colored, and 
usually foul-smelling stools. By using the top milk, diluted, we give 
a sufficient amount of fat and relieve the constipation by removing a 
considerable percentage of the casein, the usual constipating element, 
the percentage of which in the 30 ounces of food, above referred to, is 
but one-third that in full milk. Of course, the nutritive value of the 
dilution is less than that of full milk, but the child is now at an age when 
proteid can be given in other forms than in the milk. 

Diet After the Second Year. — White wheaten bread, wheaten flour 
crackers, with full raw milk should form no part of the dietary of 
these patients. It is best to give to parents of children we are treating 
for constipation a list of permissible articles of food from which 
suitable meals may be prepared. The following articles of diet may be 
allowed : 

Animal broths, purees of peas. Hashed chicken, 

beans, and lentils. Lamb chops. 

Rare roast beef. Soft-boiled eggs. 

Rare steak. 
Green vegetables, such as: 

Peas. Asparagus. 

String-beans. Strained stewed tomatoes. 

Spinach. Cauliflower, mashed. 

Cereals, as follows (each cooked for three hours) : 

Cracked wheat. Hominy. 

Oatmeal. Corn-meal. 



CONSTIPATION 243 

The cereals may be served with a small amount of milk and sugar, 
or, better, with butter and sugar. 

Bran biscuits. Zwieback. 

Oatmeal crackers. Whole wheaten bread. 

Graham wafers. 
Desserts : 

Stewed rhubarb. Corn-starch. 

Stewed or baked apple. Plain vanilla ice-cream. 

Stewed prunes. Junket. 

Custard. 

Malted milk may be given as a drink. Six teaspoonfuls of malted 
milk in 8 ounces of hot water may be given once or twice daily. An 
agreeable change in the taste of the malted milk may be made by the 
addition of a teaspoonful of cocoa. If milk is given as a drink, the 
top 10 ounces from a quart bottle should be used as described above, 
mixed with 20 ounces of boiled water or oatmeal jelly. 

A child in fair health after the second year usually thrives best 
on three meals daily. If he is delicate, or if a fourth meal does not 
interfere with the appetite for the other meals, it may be allowed. 
The extra meal, however, should be light, and is best given between 
2 and 3 o'clock in. the afternoon. For a child suffering from constipa- 
tion, this meal may consist of a cup of broth with a graham or oatmeal 
cracker. Orange-juice or a scraped raw apple may also be given at 
this time. When only three meals are allowed, the orange-juice or 
scraped apple should be given in the afternoon about two hours before 
the evening meal. The giving of the fruit-juice or the apple on an 
empty stomach is a valuable aid in relieving chronic constipation. 
These patients should also be encouraged to eat plenty of butter. The 
use of olive oil internally is of as much service here as in treating bottle or 
nursing babies. From 2 to 3 teaspoonfuls are given after each meal. 
Oil is usually well borne by the stomach; in fact, many children be- 
come very fond of it. Inasmuch as it is more of a food than a 
medicine, its use msiy be continued for months if necessary. 

Diet After the Fifth Year. — Permissible articles for a child of from 
five to ten years of age include those mentioned above, with the 
addition of dates, figs, raw and cooked fruits, baked and stewed 
potatoes, meats, baked and broiled poultry, and fish. The latter 
should be served plain, without sauce. Plain puddings may also be 
allowed. One or two raw apples, an orange, or a large peach or pear 
should be given every afternoon. It is not promised that in a case of 
chronic constipation the above diet will at once produce normal bowel 
movement. The diet must be continued for weeks in some cases before 
marked benefit will be observed ; in others the results are very prompt 
and satisfactory. 

Local Measures. — Enemata and suppositories will be necessary at 
first; until the habit of an evacuation of the bowels at a certain time 



244 THE PRACTICE OF PEDIATRICS 

every day is established. Such measures, however, should be continued 
but a very short time. 

Drugs. — Drugs may be of temporary service. The cascara prepa- 
rations are the best for this condition. If the child can swallow a 
pill or a tablet, the drug may be given in this form. The 1-grain 
tablets of cascara may be ordered, and the nurse instructed to give 
from one to three or four at bedtime. If the drug has been properly 
prepared from the well-seasoned bark, a reasonable dose will occasion 
no griping, and the amount given on succeeding nights may be 
diminished instead of increased, as is often necessary with many other 
laxatives. A most satisfactory form of medication in my hands has 
been the following combination : 

I^ Sodii bicarbonatis 5ij 

Syr. rhei aromatic! 

Fluidex. cascarse sagrada? (aromatic) aagij 

M. Sig. — 3^ to 1 teaspoonful after each meal. 

After the diet and habits of life have been arranged, the mother 
or nurse is instructed to give the prescription three times daily after 
meals, in sufficient amount to produce at least one free evacuation 
daily. The mixture is very pleasant to the taste and is well taken. 
As its administration is continued, less will be required, but it is to be 
insisted upon that the medicine be given three times daily, even though 
the dosage be reduced to three drops at a time. There is always a 
temptation on the part of those in charge of the patient to give one 
large dose at bedtime. The results are not as satisfactory when this 
is done. In a vast number of cases I have been able, with intelligent 
home cooperation, to discontinue the medication entirely after a month 
or two. 

Castor oil, calomel, or podophyllin should never be given with- 
out other indications than simple constipation. In the cases in which 
the stools are soft, but difficult of passage because of deficient per- 
istalsis, the tinctures of nux vomica and belladonna may be given with 
benefit if continued for a considerable time. A child three years of 
age may be given 3 drops of the tincture of nux vomica and 2 drops 
of the tincture of belladonna 3 times daily in tablet, capsule, or liquid 
form. The constipation which accompanies mucous colitis is referred 
to under that heading. The liquid albolene (aromatic) may also be 
used in these patients. A large dose may be required at first — 
perhaps one to two ounces at bedtime. 

Treatment of Obstinate Constipation. — Children who resist the 
above method of treatment after several months' trial may be classed 
with those who have some considerable intestinal anomaly — usually 
an elongated and often displaced sigmoid (p. 208). In these, daily ab- 
dominal massage by a skilled person, together with the diet suggested 
and the internal use of liquid albolene will prove effective. 

INTESTINAL OBSTRUCTION 

Agencies impeding or preventing the normal evacuation of the 
bowels may be either congenital — due to a malformation of some por- 



INTESTINAL OBSTRUCTION 245 

tion of the intestinal tract — or they may be acquired. Congenital 
malformation may be found in any portion of the tract, but exists most 
frequently at or near the outlet, or in the region of the duodenum. 
Silverman states that 42 per cent, of the cases of congenital malforma- 
tion involve the duodenum. Obstruction at the outlet of the bowel 
may be due to an imperforate anus, or the absence of, or atresia of, the 
lower portion of the rectum. The treatment of this deformity is 
surgical. 

The most common cause of acquired obstruction is intussusception 
(p. 233). Peritonitis, both acute and chronic, may cause a cessation of 
bowel action. Tuberculous peritonitis, through the formation of 
fibrinous bands and adhesions, may cause sufficient constriction of the 
gut to prevent the passage of the intestinal contents. In such cases, 
also, relief is best furnished by surgical measures. 

Acute infective peritonitis (p. 256), producing a complete cessation 
of peristalsis, acts indirectly as a means of preventing the normal pas- 
sage of the bowel contents. The infection is usually secondary. 
Operative procedures may be attempted, but all my cases have been 
fatal. Two underwent operation, as it was feared there might be an 
intussusception or a volvulus. In one case peritonitis followed pneu- 
monia, the infection being due to the pneumococcus. 

Strangulated hernia is a condition by no means difficult of diagnosis 
and demands prompt surgical relief. 

Intra-abdominal tumors, such as sarcoma of the kidney and hydro- 
nephrosis, may cause obstruction through pressure on the intestine. 

Illustrative Cases. — Fecal impaction was found in two of my cases of intestinal 
obstruction. Both were seen in consultation. There had been prolonged con- 
stipation with insufficient evacuations, owing to neglect on the part of the attend- 
ants. The duration of the condition it is impossible to state, as the children were 
permitted to go to the toilet alone, and as both were under five years of age, but 
little dependence could be placed upon their testimony. In both cases enemata 
and cathartics had been tried in vain. There was vomiting and slight abdominal 
distention. There was no fever and no marked tenderness on pressure. In my 
opinion, the vomiting was due chiefly to the medication, for it ceased when drugs 
were discontinued. Both children responded to massage and injections of molasses 
and water. Eight ounces of molasses and eight ounces of water were introduced 
by means of a rectal tube at intervals of four hours. One case was relieved after 
the second injection, the other after the fourth. Massage w^as early brought into 
use. This was given for thirty minutes and repeated after an interval of ninety 
minutes. The interrupted massage was continued until an evacuation occurred. 

An unusual case of intestinal obstruction was seen in a wretched, premature 
infant, five months of age, weighing about seven pounds. The child had a con- 
genital heart lesion and deformities of the ears. He was suddenly taken ill w^ith 
vomiting, and the passage consisted of pale mucus streaked with blood. No tumor 
could be felt, but a diagnosis of intussusception was made and the abdomen opened. 
At the site of the obstruction was a IXIeckel's diverticulum which had twisted the 
gut so as to prevent the passage of gas or intestinal contents. 

Paralytic Ileus. — Two infants under one year of age, iU with 
severe intestinal toxemia, developed intestinal obstruction with marked 
abdominal distention. Exploratory abdominal incision in one and 
autopsy in the other failed to show any abnormality. 



246 THE PRACTICE OF PEDIATRICS 

INTESTINAL CYSTS OR DIVERTICULA (CONGENITAL) 

A most unusual case of intestinal obstruction recently came under 
my care. A well-nourished, breast-fed child, five weeks of age, became 
ill with what appeared to be intestinal indigestion. There was a sHght 
elevation of the temperature, and the stools were green, undigested, 
and watery. The family physician, Dr. Walter Fleming treated the 
case by the usual methods. An improvement in the stool followed, 
but a marked degree of tympanites remained. Feces and gas were, 
however, passed in small amounts, and at times the abdomen was 
sufficiently soft to allow of free palpation. The tympanites gradually 
increased, and instead of being intermittent, persisted. About one 
week after I first saw the case it came under my immediate supervision 
in New York City. 

Feces and gas were passed with difficulty — occasionally there was a 
fairly large stool. The child was in no way ill, and suffered only from 
the abdominal distention; when this was relieved, the baby took food 
well and was content. In spite of our every effort in regard to diet, 
medication, local measures to the abdomen, and colonic treatment, the 
condition of tympanites gradually increased and became permanent 
and extreme. 

The patient was sent, at about the sixth day under my observation, 
to the Babies' Hospital, where all means and attempts at reduction of 
the gaseous distention were likewise futile. 

An exploratory incision was made into the abdominal wall by Dr. 
Wm. A. Downes, who discovered a tumor in the cecum. An artificial 
anus was made in the ileum above the valve, and the tympanites was 
relieved; but the child died shortly from exhaustion. 

A postmortem examination showed just above the ileocecal valve, 
and within 5 cm. of it, a round, sessile cyst, 3 cm. long and 2.5 wide by 
0.75 cm. high, the mucosa over it thin, stretched, congested at either 
side, pale on top, with dilated vessels from the base radiating over the 
sides and top. Immediately beyond was a second cyst, 2.5 x 2.5 cm. 
and only 0.25 high; close to it, almost bilocular, was a third, 2.5 x 2 
and 0.75 cm. high. Contents showed mucolymph within a smooth 
lining. Between the mucosa and submucosa the muscle was normal. 
Next to the last cyst was a part of a Beyer's patch, mucosa congested, 
walls thickened and edematous. The colon was congested. 

The cysts or diverticula had encroached upon the lumen of the gut, 
and because of their proximity, formed a sufficient obst^-uction to pre- 
clude the passage of gas and the intestinal contents. Evidently the 
later growth of the cysts was quite rapid, as the obstruction caused 
symptoms increasing only gradually in severity, and permitted of the 
passage of feces until a day or two before the operation. 

Blackader, of Montreal, reported a similar case before the American 
Fediatric Society in June, 1913. He was able to find records of but 
three other cases of congenital intestinal cysts in the literature. The 
condition, according to Gant, is not uncommon in adults; and in them 



THE INTESTINAL PARASITES 247 

the cysts are usually found in the sigmoid and colon and are looked 
upon as acquired. 

THE INTESTINAL PARASITES 

The most common of the intestinal parasites found in children are 
Ascaris lumbricoides, or round-worm, Oxyuris vermicularis, or thread- 
worm, Tenia, or tape- worm, and Uncinaria, or hook-worm. 

The Blood in Infections by Intestinal Parasites. — Patients with 
teniasis or uncinariasis frequently present a pronounced degree of ane- 
mia of the chlorotic type. In occasional cases of tape-worm infection 
the blood-picture resembles that of actual pernicious anemia. Where 
uncinariasis is prevalent and the inhabitants are subject to constant 
infection from the soil, such terms as ''Egyptian chlorosis," ''miner's 
anemia," and " brickmaker's anemia" are current synonyms for the 
disease. 

Leukocytosis in the parasitic infections is not characteristic, but 
may occur during the acute stage of trichiniasis. Eosinophilia, how- 
ever, is a very characteristic manifestation of reaction to the parasitic 
toxins, and in trichiniasis often attains a degree of 20 to 50 per cent. 
Stiles reports that in uncinariasis the chronic cases with poor resistance 
show little eosinophilia, while those undergoing improvement under 
treatment afford counts averaging as high as 13.2 per cent.* 

Ascaris Lumbricoides (Round-worm). — This parasite is a very fre- 
quent inhabitant of the small intestine. The worm is 5 to 10 inches 
long, cylindric in form, and closely resembles an ordinary earth-worm. 
Large numbers may exist in the same patient, and have been known to 
cause serious secondary symptoms, such as obstruction of the bile- 
duct or a severe attack of choking, induced by the migration of the 
worms from the esophagus into the larynx. They have been known to 
invade the Eustachian tube. The ova are taken into the digestive 
tract in uncooked food and occasionally in drinking-water. The eggs 
are of oval form, and when present in the feces, may be distinguished 
by their thick shells and " mammillated " borders and by the absence 
of segmentation. 

Symptoms. — The round-worms, if in considerable number, may 
produce colic or constipation, the latter oftentimes alternating with 
diarrhea. Nervous disturbances of an urgent character are not un- 
common. In the great majority of my cases, however, no symptom 
whatever was present, and the fact that the child had parasites in the 
intestine was first learned when a worm was found to have been passed 
by the rectum. In the case of one of my patients, three years of 
age, there were repeated convulsions. The mother stated that the 
child had passed a couple of round-worms the day before. I gave one 
ounce of castor oil, and after an hour, two grains of santonin. Forty- 
three large round-worms were passed during the next twenty-four 
hours. This is the largest number I have known to come from one 
child. The round-worm is rare in New York City children. I have 

* Osier's Modern Medicine, vol. i. 



248 THE PRACTICE OF PEDIATRICS 

seen but five cases. In children who Uve in the country it is of fairly 
common occurrence. 

Treatment. — At bedtime I order from 2 to 4 teaspoonfuls of castor 
oil. Early the following morning, about two hours before breakfast, 
santonin is given. To children under two years of age I give 1 grain; 
to those from two to four years of age, IJ^^ grains; and after the fourth 
year, 2 grains. The santonin is prescribed in a powder or capsule, 
with an equal quantity of sugar-of-milk. If the passage of worms 
follows its use, the treatment is repeated in three days; and again in a 
week, if worms are passed after the second treatment. 

Oxyuris Vermicularis (Thread -worm or Pin -worm). — Thread- 
worms are of more frequent occurrence in city children than are either 
round-worms or tape- worms. The thread-worms have their habitat in 
the lower portion of the colon, where they become attached to the 
mucosa, and occasionally produce considerable catarrhal inflammation. 
The oxyuris is an insignificant looking object, light in color, from 3-^ 
to J'^ inch in length, and of the diameter of a pin. The ova are not so 
large as those of the ascaris. Raw fruit and uncooked vegetables may 
convey the infection. 

Symptoms. — The worms produce an irritation and itching about, 
and a pricking sensation within, the anus. The discomfort is bitterly 
complained of after the child is in bed at night, the parasites being 
particularly active at this time. If there is any doubt as to their 
presence, the patient should receive a full dose of castor-oil — at least 
two teaspoonfuls. The discharges should be kept for inspection. 
If the parasites are present, they will usually be found embedded in a 
considerable quantity of mucus, in the form of pieces resembling white 
thread from }^ to 3^^ inch in length. 

Treatment. — Santonin, recommended by some writers as of service 
in these cases, has been without the slightest value in my hands. In 
fact, the use of drugs of any kind seems to be of very little value. After 
the third year turpentine in one-drop doses after meals is probably 
the most valuable form of internal medication. It may be given in 
emulsion or dropped upon sugar. 

Rectal Injections. — ^Local treatment with the infusions of garlic 
or quassia is our principal reliance in the management of the obsti- 
nate cases. In patients in whom the worms have existed for a con- 
siderable time the resulting irritation causes a profuse secretion of 
mucus in the descending colon and sigmoid. This mucus must be 
washed out before any direct treatment can be effective. The colon 
should first be irrigated with a solution of one tablespoonful of borax 
to a pint of water. For this purpose a No. 18 American catheter should 
be used, as in colon flushings. The tube should be introduced at 
least 10 inches. The child should be encouraged to bear down and 
expel the water alongside the tube, no attempt being made to have the 
solution retained. After the preliminary washing is complete, eight 
ounces of the infusion of quassia may be passed into the colon. To 
facilitate retention of the fluid the tube must be quickly withdrawn. 



THE INTESTINAL PARASITES 249 

The child may then be placed on the left side, with the buttocks elevated 
on a pillow. This position, or at least the recumbent position, should 
be maintained for one half -hour after the injection is given. A solution 
of the bichlorid of mercury 1 : 10,000 may be used in the same way. 
For ordinary family use, however, I consider either the garlic or the 
quassia much safer and equally effective. Garlic used in infusion 
identical with quassia is particularly effective, but its very disagreeable 
odor makes its use objectionable in many households, and therefore I 
advise it only when other means fail. After the worms and all evidences 
of their presence disappear, the treatment should be continued for a 
time on alternate days, and then twice a week, gradually reducing the 
frequency of the irrigations until they are no longer required. Few 
cases recover in less than four weeks, and in many it will be found 
necessary to continue the treatment for months. I have never seen a 
case, however, which did not eventually respond to persistent 
treatment. 

Tenia or Tape-worm. — The tape- worm is along, flattened organism, 
consisting of a head or scolex and hundreds of individual proglottides 
or offshoots derived from the head. Each segment in the series contains 
a large number of eggs. After the discharge of the segments from the 
body these ova are ingested and undergo a period of development in 
the tissues of an intermediate host, eventually forming the cysticerci 
or encapsulated bladder-worms which give the ''measle" appearance 
to infected meat. This meat, when insufficiently cooked, conveys 
the cysticercus to the stomach of the patient, where the digestive 
juices liberate from the cyst- wall a head which is capable of becoming 
attached to the mucosa of the child 's alimentary tract and producing 
a mature parasite. 

The chief varieties of tape- worm are the Taenia saginata, or beef- 
worm, the Taenia solium, or pork-worm, the Bothriocephalus latus, an 
inhabitant of fish, and the Taenia elliptica, which passes an intermediate 
stage in the vermin of household pets. 

The Taenia saginata attains a length of from ] 2 to 20 feet. The 
head is from 1 to 2 mm. in diameter, and contains four suckers, but no 
booklets. 

The Taenia solium is rarely over 12 feet long. The offshoots from 
the median canal forming the uterus of a segment show less branching 
than in the case of Taenia saginata, and the developed segments in 
Taenia solium are more nearly square. The head has a short rostellum 
with a circle of booklets. 

The Bothriocephalus latus is far more common in northern Europe 
than in America. When mature, this worm is over 25 feet long. The 
segments are unusuallj^ broad, and the head is oval in outline and 
contains two lateral grooves. 

Taenia elliptica occurs occasionally in very young infants. It is 
only 6 to 12 inches in length, and its segments are long and narrow. 

Symptoms. — The tape-worm may produce symptoms of disturbed 
intestinal digestion, such as colicky pain and diarrhea. Usually, 



250 THE PRACTICE OF PEDIATRICS 

however, the first warning that the child is affected is afforded by the 
passage of segments of the worm. 

A worm 14 feet in length was expelled, after treatment, by a little 
girl four years old. There had never been a symptom of its presence 
other than the passage of several of the segments. 

A child, eighteen months of age, under my care, has passed 18 feet 
of a tape- worm without dislodging the head. 

Treatment. — At bedtime, H ounce to 1 ounce of castor oil is given. 
Early next morning, two hours before breakfast, 3^^ dram of the oleoresin 
of male-fern (aspidium), in emulsion or in capsule, is given. During 
the day a light fluid diet only is allowed, such as broth, gruel, and fruitr 
juices. One treatment with a good preparation of the male-fern will 
usually bring away the worm entire. The head should be care- 
fully searched for with the magnifying-glass. If the head is not found, 
the treatment should be repeated after an interval of twenty-four 
hours. 

Uncinaria; Hook-worm. — The two forms of this parasite, An- 
kylostoma duodenale and Uncinaria americana, exhibit certain morpho- 
logic differences, the most marked of which is the existence, in anky- 
lostoma, of two pairs of ventral, hook-like teeth, which are not present 
in the American species. The hook-worm measures from }^ to ^^ inch 
in length. The ova, in large numbers, are present in the feces, and 
may be recognized as small oval bodies, usually clear in appearance, 
about 50 M X 30 /x in size, showing various stages of segmentation. 
After the administration of thymol, followed by a saline cathartic, 
the worms themselves may appear in the stools as small objects, a little 
thicker than a pin, about }i inch long, and with the characteristic, 
retro verted hooked end. 

The hook-worm has been known for many generations, but only 
during the past ten years has uncinariasis received due attention. 
In certain localities — notably the West Indies and the Southern States 
— the soil is very generally infected, and a considerable proportion of 
the population harbor the parasites. These not only remove blood 
from the circulation of the victim, but elaborate a toxin which is thought 
to assist in the causation of the significant anemia of this disease. In- 
fection usually takes place from the soil, through the skin of bare feet. 
Infection may also take place through the skin of the hands, or by 
means of the gastro-intestinal tract, through the use of raw fruit or 
vegetables. 

Symptoms. — The symptoms are those of digestive disturbance 
combined with progressive anemia. The anemia is often of an extreme 
degree. Abdominal discomfort of considerable degree may exist 
and this possibly gives rise to the curious habit of earth-eating, which 
these patients may acquire in their desire for the relief which the 
ingestion of food usually affords. Stiles reports a case in which a boy 
ate three coats, thread by thread, in twelve months. As the disease 
progresses, the face and ankles may become edematous. The stools 
contain occult blood. Lassitude and incapacity for sustained effort 



THE INTESTINAL PARASITES 251 

are prominent symptoms, and unless the cause of the disease is eHmi- 
nated, the child falls behind in physical and mental development. 

Treatment. — Thymol is specific for the hook-worm. A purgative 
should precede the administration of the drug. Twelve hours before 
administering the thymol a full dose of cascara sagrada or epsom salts 
should be given. The thymol should be given in solid form, 5 to 10 grains 
every three hours until four doses have been given. The drug is best 
given in capsules or pills. Twelve hours after the last dose, a saline 
cathartic should be administered. Ten days after the administration 
of the thymol the stools should again be examined for the ova of the 
parasite, and if ova are found, the treatment should be repeated. 
Thymol poisoning is indicated by dizziness and discoloration of the urine. 
When these symptoms appear, the treatment should be discontinued 
and further purgation brought into use. During the active treatment 
the diet should consist of milk, broths, and gruels. 

The anemia and malnutrition should be managed along the lines 
suggested under the respective headings. 

Trichiniasis is a disease which children may occasionally acquire 
from the eating of uncooked ham, sausage, or pork. In localities where 
meat inspection is rigid, cases of this infection are relatively rare. 
The Trichina spiralis (Trichenella spiralis) is not infrequently found 
in hogs. The female parasite deposits larvae in the submucosa, whence 
they are carried by the lymphatics to the blood-stream, and on reaching 
the voluntary muscles, become encapsulated. When the uncooked, 
infected meat is eaten, the capsules undergo dissolution, and the con- 
tained trichinae are liberated in the digestive tract of the patient. The 
forms attain full development in the small intestine, and about a week 
after the ingestion of the meat set free a new brood of embryos. 

Van Cott and Lind* found the trichina spiralis in the cerebro- 
spinal fluid. These findings have since been confirmed by Young, 
Cummins and others. In doubtful cases an examination of the cerebro- 
spinal fluid supplies a possible medium for the confirmation of a 
diagnosis. 

Symptoms. — The severe symptoms of trichiniasis develop about 
ten days after the eating of the infected meat, frequently following 
a period of preliminary gastro-intestinal disturbance. When well 
advanced, the disease may be mistaken for typhoid, malaria, influenza, 
or acute rheumatism. Fever of a remittent type, great muscular pain 
and soreness, and edema of the face and eyelids suggestive of nephritis 
are the more pronounced effects. The blood shows not only leukocyto- 
sis, but a marked grade of eosinophilia. The symptoms usually subside 
after a week or ten days. Romanowitch has shown that in traversing 
the intestinal mucosa the trichina deposits bacteria which may dis- 
tribute secondary infections. How important this fact may be in the 
explanation of symptoms occurring in this disease remains to be de- 
termined. In doubtful cases trichiniasis may be diagnosed by the mi- 
croscopic demonstration of the encapsulated parasites in a bit of muscle 
* Journal A. M. A., vol. Ixvi, No. xxiv. 



252 THE PRACTICE OF PEDIATRICS 

tissue removed under local anesthesia from the deltoid, biceps, or 
gastrocnemius of the patient. 

Illustrative Case. — A girl eight years of age consulted me because of muscle 
soreness, edema of the skin, and especially marked swelling and stiffness of the 
muscles of the left leg. Trichiniasis was suspected, and a small portion of the 
deltoid was removed, which showed the encapsulated parasite. 

Treatment. — At the outset of the disease thorough catharsis is of 
unquestionable value, for it has been estimated that "each female 
parasite removed from the intestine means a reduction of the muscu- 
lar infection by from 1500 to several thousand worms."* Calomel 
is undoubtedly indicated for this purpose, and this drug should be 
given in doses aggregating 1 to 2 grains, accompanied by 10 to 20 
grains of bicarbonate of soda, and followed after six hours by a saline 
cathartic. Thymol may be given in the manner suggested under 
treatment of uncinariasis, but the position of the parasites deep in 
the intestinal mucosa renders most of them secure from the action 
of an anthelmintic. After the disease has become established, the treat- 
ment is solely symptomatic, consisting in the use of means to relieve 
pain, control temperature, and support the pulse, which in severe 
infections may become weak. 

APPENDICITIS 

The Appendix. t — This organ, normally, is located in the right 
iliac fossa, subjacent to McBurney's point, which marks the junction 
of the two lower thirds of a line connecting the right anterior su- 
perior iliac spine with the umbilicus. This position is attained as 
the result of intra-uterine changes in the intestinal canal, involving 
a gradual migration of the ileocolic junction from a primary position 
in the left iliac fossa upward to the right, beneath the liver, and finally 
downward into the right iliac fossa. When these changes are not com- 
pleted, the organ will not be found in its normal adult location, but 
frequently higher up. Because of variations in development the ap- 
pendix may or may not have its origin from the extreme lower portion 
of the cecum. The lumen of the appendix at its base is, moreover, 
often very minute. Both of these facts partially explain the liability to 
inflammation. The total diameter of the organ is about 3^ inch, and 
the length, which is extremely variable, is usually between 2 and 3 
inches. Various abnormalities in shape and direction occur, chiefly 
as a result of peritoneal adhesions. 

The appendix contains serous, muscular submucous, and mucous 
layers. It is, however, essentially a lymphoid structure, well deserving 
the name '^ abdominal tonsil." Like the tonsil, it attains its maximum 
development early in life, and, with the occurrence of the atrophic 
changes common in later years, shows a diminished susceptibility to 
infection. 

Appendicitis is not so rare a disease of early childhood as is usually 

* C. W. Stiles: Osier's Modern Medicine, vol. i. 

t Vide: "Anatomy and Physiology of the Appendix," by Dr. Andrew McCosh^ 
in "American Practice of Surgery," Bryant and Buck, vol. vii, p. 618 et seq. 



APPENDICITIS 253 

taught. It occurs with sufficient frequency for the practitioner not 
to forget the possibihties of its unexpected development. 

I am confident that both acute and chronic cases are often over- 
looked because of the difficulty in diagnosis. In describing appendicitis, 
writers are inclined to divide the disease into types such as catarrhal, 
suppurative, gangrenous, and perforative. Such division is hardly 
possible. Because of the excess of lymphoid tissue in the child 's ap- 
pendix, the pathogenic process may be extremely active, and a case 
that is catarrhal today may be gangrenous tomorrow. Not all ca- 
tarrhal cases go on to the later stages. Nevertheless, it must always be 
remembered that appendicitis in the child is usually a much more ac- 
tive disease than in the adult. 

Age. — No age appears to be exempt. My youngest patient was 
nine months of age. Shaw reported the case of a patient seven weeks 
of age. My own cases have been in children ranging from nine 
months to fourteen years. 

Symptoms.- — ^That many errors are made in the diagnosis of ap- 
pendicitis in infants and young children is beyond doubt for the 
reason that the cardinal symptoms, as laid down by writers, viz., 
vomiting, colic, and sensitiveness to pressure, do not complete the 
symptomatology- . Pain is a relative term, and the complaint of pain, 
while it must be respected, is never to be relied upon. Some children 
will exaggerate the sensitiveness of the abdomen to pressure, and others 
will deny the existence of pain actually present. Vomiting and colic 
are very unreliable signs. Fortunately in children one sign is almost 
invariably present unless there is a malformed or misplaced appendix, 
which is most unusual. The sign of real value indicating an involved 
appendix in a child is localized muscle rigidity — a spastic right rectus. 
This symptom is entirely beyond the child's control, and while young 
children may be difficult to approach, patience in gaining the child's 
confidence, combined with attempts at diversion, will make a satis- 
factory examination possible. 

Deep pressure is not necessary. If both recti are persistently 
rigid, as I have seen in a few cases, the fact in no way disproves the 
presence of a diseased appendix. The signs usually given — vomiting, 
pain, and colic — are corroborative when there is a spastic right rectus. 
Alone they are suggestive of appendicular disease in children, but not 
diagnostic. 

With the rigidity and unusual sensitiveness to deep pressure, there 
is a tendency to flexion of the thigh on the abdomen, to relieve the 
tension of the abdominal muscles. 

Atypical cases may be seen, and in my experience have always been 
due to an abnormally long appendix. Thus, in the case of a boy of 
twelve years, the appendix was 6 inches long and the abscess was 
located in the tip, which was in the right hypochondrium. In this 
case there was general muscle rigidity. 

In an eight-year-old child the diseased appendix was situated 
deeply in the pelvis. There was no pain or rigidity. Appendicitis was 



254 THE PRACTICE OF PEDIATRICS 

not diagnosed until rupture occurred and an acute localized perit- 
onitis developed. 

In another child, with a very long appendix, the local symptoms 
were all referred to the left side. Operation was delayed, through no 
fault of mine, until abscess and peritonitis developed. The tip of the 
gangrenous appendix was located two inches to the left of the median 
line. 

Leukocytosis. — A leukocytosis has been present in all my cases, 
the differential count showing 70 per cent, or over of polymorphonuclear 
cells. 

Exploratory Incision. — After a considerable experience with 
obscure acute and chronic abdominal conditions in children I have 
learned that an exploratory incision should be made as soon as we 
realize we are not positive regarding the character of the trouble at 
hand. This has been learned through experiences which I regret. 

Prognosis. — The prognosis depends upon the ability of the physician 
to diagnose the disease, his courage to act promptly, and the good 
sense of the family. In the young, appendicitis is usually of the ful- 
minating type, and while temporizing may answer in the adult, it may 
be fatal in the child. Statistics of high mortality mean defective man- 
agement. In children over two years of age the results should be as 
favorable as in adults. If one uses ice-bags, stupes, and salines for 
three or four days and then operates, there will be a large mortahty. 

Diagnosis. — The chief diagnostic symptom is rigidity of the abdomi- 
nal muscles, usually localized in the right side, sometimes general. 
I have seen marked general rigidity in a girl eleven years of age, in 
whom the appendix had not perforated. This symptom, with localized 
tenderness and the presence of a tumor, is to be looked upon as an 
independent diagnostic sign. All other symptoms to which much 
importance is attached are only of corroborative value. * 

Differential Diagnosis. — In cases of intussusception and periodic 
vomiting there is no muscle rigidity, and in periodic vomiting, no local- 
ized tenderness. 

Acute peritonitis may simulate a later stage of atypical appendicitis 
so closely that a differential diagnosis is impossible without an explora- 
tory incision. This should always be done in either event, whether 
there is a pyogenic peritonitis or peritonitis due to intussusception. 

Acute pneumonia at the right base, with pleurisy, may produce 
signs closely simulating appendicitis, and is one of the conditions that 
may produce a spasm of the right rectus. 

With pneumonia and pleurisy there are the unmistakable physical 
signs, the respiratory grunt, high temperature, and usually cough, to- 
gether with the objective sign of rapid breathing — signs ordinarily 
sufficient to eliminate an error in diagnosis. In cases in which the 
physician feels that a differentiation is impossible the a; -ray may be 
brought into use to clear up the situation. 

Treatment. — The treatment of proved acute appendicitis in chil- 
dren demands operation as early as possible. For the borderland case, 



CHRONIC APPENDICITIS 255 

with mild symptoms in which a positive diagnosis is not possible, rest 
in bed, a fluid diet without milk, and the ice-bag comprise the essentials 
in a scheme of treatment which may suffice. The recumbent posi- 
tion and quiet should be maintained until every sign of the trouble has 
disappeared. 

Interval Operation. — In the event of the child's recovering from a 
well-defined attack without operation a suitable time should be selected 
for an interval operation. A second attack is very liable to follow 
in less than a year, with a strong probability of abscess formation. 
Furthermore, we cannot time the subsequent attacks, and these may 
occur with great severity when the child is otherwise ill or away from 
home where necessary surgical skill may not be obtainable. 

CHRONIC APPENDICITIS 

Chronic appendicitis has a very decided entity. It occurs in older 
children. I have never seen a case before the fourth year. In 
pediatric consultation practice it is not unusual to find the condition 
after this period. 

Symptoms. — The cases usually show one or two groups of symptoms. 
Two cases show symptoms of both types. 

A child in apparent health has complained of frequent abdominal 
pain over a period of several months. If asked to place his hand over 
the painful area, he will almost always place it over the umbilicus. 
There is no apparent sensitiveness over the appendix, no pain on deep 
pressure, and no rigidity of the recti. The pain is rarely severe and 
may occur at considerable intervals. In some cases the abdomen will 
never feel quite comfortable. There may be diarrhea alternating with 
constipation, or the stool may be perfectly normal and regular. In 
others unwarranted attacks of acute intestinal indigestion may occur, 
the occasion of which will not be explained by the habits of the patient. 

The other type of case shows periodic, acute manifestations. These 
include vomiting, fever, and colicky pains, with diarrhea. There may 
be two or more attacks during the year. As in the cases of the first 
type, there may be no localization of signs in the abdomen. 

Periodic or recurrent intestinal disturbances — so-called indigestion 
— that is not relieved by a rational life and careful feeding will usually 
be found due to either an elongated sigmoid (p. 208) or to a chronic 
appendicitis. 

Comby believes that many cases of cyclic vomiting have their 
origin in chronic appendicitis, and he claims to have cured a considerable 
number of such cases by removal of the appendix. 

Treatment. — Suspicious cases should be given an anesthetic 
after fasting for twelve hours, and then examined by deep palpation 
and through the rectum. If tumefaction is found in the right iliac 
fossa, operation for the removal of the appendix should be performed 
at the convenience of the patient. 

A badly diseased appendix, as large as an adult index-finger, was 



256 THE PRACTICE OF PEDIATRICS 

recently removed from a fourteen-year-old patient in whom there had 
been no localized symptoms other than a feeling of pressure or weight 
in the right side, but who always had, as he expressed it, an uncomfort- 
able abdomen. 

ACUTE GENERAL PERITONITIS 

Acute general suppurative peritonitis is an infection of the peri- 
toneum by pathogenic organisms. It is always a secondary disease, 
and its bacteriologic factor is that of the primary lesion. Thus, perit- 
onitis may follow umbilical infection in the newly born, usually due 
to the streptococcus or to the staphylococcus aureus. It may be one 
of the lesions resulting from a general blood infection with the pneumo- 
coccus, the influenza bacillus, or streptococcus, whether the point of 
entrance be the upper respiratory tract or a surgical wound. Peritoni- 
tis may follow appendicitis, enterocolitis, or intestinal obstruction, and 
is then most often due to Bacillus coli communis, with or without the 
streptococcus. It may be due to the gonococcus, as the result of the 
progressive spread of vulvovaginitis, endometritis, and salpingitis 
in little girls. It may be due to the Bacillus typhosus in the course 
of typhoid fever. Finally, peritonitis may result from the extension of a 
pleural inflammation by means of the lymphatics, but the inflammation 
is then more often localized about the spleen or liver than generalized. 

The pneumococcus probably is the pathogenic agent in more than 
half the cases. 

PERITONITIS AS A COMPLICATION 

The disease as a complication is not infrequent. I have seen 
cases with scarlet fever, with enterocolitis, with appendicitis, with 
endocarditis, with pneumonia and with empyema. 

Pathology. — The exact character of the inflammation depends 
upon the infecting organism. The process, however, uniformly in- 
volves congestion, exudation of serum and lymph, and the formation 
of adhesions. Depending on the source and degree of infection, 
peritonitis may be localized, spreading or general, and serous, sero- 
purulent, purulent, or fibrinous. The most frequent infecting agents 
are the colon and the typhoid bacillus and the streptococcus, staphylo- 
coccus, pneumococcus, and gonococcus. In cases of streptococcus- 
peritonitis the fluid is thin and widely diffused, and in pneumococcus 
infections, thick, greenish-yellow, purulent, and associated with fibrinous 
deposits and many adhesions. Gonococcal peritonitis is seldom diffuse. 
Pus with a characteristic fecal odor is suggestive of appendical or 
intestinal perforation. When the peritonitis is of limited extent, the 
most common sites for the localization of the inflammation are the iUac 
fossa, pelvis, and subdiaphragmatic regions. Abscesses occasionally 
perforate spontaneously at the umbilicus. When recovery ensues, 
the peritoneum frequently becomes the seat of permanent adhesions 
which may or may not occasion symptoms. 

Symptoms. — There are but three diagnostic symptoms of value: 
persistent vomiting, marked tympanites, and obstinate (and often 



PERITONITIS AS A COMPLICATION 257 

absolute) constipation. These manifestations comprise a symptom- 
complex that is always present in acute peritonitis. 

The temperature is usually persistently high — 103° to 105°F. 
The pulse is small, soft, and quick, and the child appears and is 
very ill. The respiration is short and rapid; there is incomplete 
expansion. There are no evidences of pain except upon manipulation. 
The onset of all symptoms is usually, but not invariably, abrupt. It 
may be two or three days before the symptom-complex as described 
is present. 

Duration and Prognosis. — Death rarely occurs before the third 
day, and the cases that pass ten days are rare. I have never known 
a case to recover. My cases have all been in children under two 
years of age, with two exceptions. One was a child of three with a 
streptococcus infection occurring with endocarditis. The other pa- 
tient, a strong, vigorous girl, three years of age, developed a moderately 
severe enterocolitis. Response to treatment was fairly prompt, and in 
ten days the child was convalescent. Suddenly she developed marked 
distention of the abdomen, persistent vomiting, and obstinate con- 
stipation. These symptoms, with gradually increasing prostration, 
continued for three days, when the child died. The autopsy showed 
an acute general streptococcic peritonitis. Streptococcus was found 
in the enlarged mesenteric glands, proving that the intestinal tract 
was the source of the infection. The prognosis in older children after 
the fifth year is said to be more favorable. 

Differential Diagnosis. — The only condition which the foregoing 
may simulate in infants and runabouts is intestinal obstruction, 
particularly that due to intussusception. Intussusception in a large 
majority of the cases occurs in infants under a year of age. Further, in 
intussusception there is no associated illness, and fever, if present, is 
insignificant; while the stools almost always contain blood-stained 
mucus or clear white mucus. I am conviced that every case of acute 
peritonitis in a young subject should have the benefit of an exploratory 
incision. There is always a possibility in obscure cases (and most cases 
are obscure) that the trouble is of appendicular origin or that there may 
be some other localized process which drainage might relieve. Acute 
general peritonitis is a very fatal disease, and the outlook cannot be 
made worse by incision and drainage. 

Treatment. — Obviously, it would be unsatisfactory to the reader 
to have the treatment of a disease outlined by one who has never seen 
a recovery from the disease in question. My practice is to call a 
surgeon, who usually refuses to operate. An exploratory incision 
does not remove any of the chances of recovery, and there is always 
the hope that drainage may be of value. 
17 



VI. THE RECTUM AND ANUS 

THE RECTUM IN CHILDREN 

In the child, the division between the pelvis and abdominal cavities 
is less marked than in the adult, and the rectum is less distinctly a 
pelvic organ. The infantile pelvis, moreover, is peculiarly narrow, 
so that the course of the terminal portion of the intestine is nearly 
perpendicular. This pecuUarity, combined with the greater mobility 
of the child 's rectum, renders digital examination per rectum of great 
value in palpating diseased organs within the abdomen. The same 
anatomic conditions, associated with weakness of the levatores ani, 
are influential in the causation of prolapsus recti in children. 

PROLAPSE OF THE ANUS AND RECTUM 

In anal prolapse there is an eversion of the mucous membrane, 
a condition often presented in constipation and sometimes seen in 

diarrheal conditions of the dysenteric 
^"' ' type, in which there is a tendency to 

^ _ «. considerable tenesmus and straining. 

Hmt '" If the case is neglected, the prolapse 

^H 1^ occurring repeatedly for many days 

|H[ Hj in succession in cases of constipation, 

^H (^^^ Ih ^^ several times a day in the acute 

^H ^^^P ni diarrheal cases, the sphincter gradu- 

^|B '*|.i"""^ . JH ally becomes weakened, the prolapse 
^Ib ' J^H "^^^^ pronounced, and soon a con- 

^^B JIh siderable portion of the involuted 

^^H ^flH rectum appears with each defecation. 

^^^■^ _1 jI^^I (See Fig. 24.) Such children usually 

Fig. 24.-Prolapse of rectum and ^^^^ evidence of illness apart from 
anus. the local condition and the constipa- 

tion. They are usually underfed and 
poorly nourished. Many are rachitic, or show the ear-marks of a 
previous rachitic state. 

Treatment. — Cases of simple eversion are usually relieved by con- 
trolling the diarrhea'; or, when due to constipation, by supporting the 
perineum during defecation. This support is best furnished by wrap- 
ping a considerable quantity of absorbent cotton around the index- 
finger, which rests against and supports the perineum. The child 
should lie on the back during defecation. The troublesome cases are 
those due to constipation in ''runabout" children, in whom the pro- 
lapse has been repeated every day for several months. In such cases 
a wide adhesive strip placed across the buttocks, high enough to permit 

258 



PROLAPSE OF THE ANUS AND RECTUM 



259 



of bowel evacuation, will often prevent the prolapse. The case rep- 
resented in Fig. 25 was brought to the New York Polyclinic in the 
condition shown in the cut, and was transferred to the service of Dr. 
Wm. Seaman Bainbridge, The gut was practically black, and its 
condition raised the question whether there was not sufficient strangu- 




Fig. 25. — Involution of the rectum, sigmoid, and a portion of the descending colon. 



lation even if reduced, to cause death. Hot applications were placed 
upon the gut, and it was gradually reduced, but prolapse immediately 
followed. In order to keep the gut in position a long rubber tube of 
large caliber was inserted into the rectum and passed into the gut as 
high as possible. The rectum was then sewed tightly around the tube, 



260 THE PRACTICE OF PEDIATRICS 

anchoring the rectal outlet to the tube by a double purse-string suture 
of strong silk. The bowels moved through the tube, and for days there 
was great improvement. The use of the long tube held up the gut. 
Later the child died of pneumonia, but it was possible to remove the 
tube and then prolapse did not take place. 

INFLAMMATION OF THE ANUS 

An acute painful inflammation of the anus and of the skin surround- 
ing it is frequently seen in children after a diarrhea of some days' dura- 
tion. It is also seen in weakly, delicate children without any marked 
intestinal disturbance. The inflammation produces considerable dis- 
tress during the passage of a stool, and is conducive to constipation, 
because the child soon dreads to have a bowel movement and tries to 
avoid it. 

Treatment. — The child's nutrition and management in general 
must be first carefully looked after, as elsewhere suggested (p. 105). 
For the local trouble, the free use of warm water after each defecation 
is necessary. This is to be followed by a generous application of an 
ointment made as follows. 

I^ Ichthyolis 5 j 

Unguenti aquse rosse 5 j 

Instructions are given that the parts are to be kept covered with the 
ointment, applied on a piece of old linen, which should be changed 
every three hours. This treatment is usually followed by prompt 
relief. 

FISSURE OF THE ANUS 

Anal fissure is a condition that usually occurs in quite young chil- 
dren. I have seen comparatively few cases in those over two years of 
age. Rough manipulation may be a cause, as in the case of unskilled 
use of the syringe or rectal tube. With very few exceptions, however, 
the fissure is due to the stretching of the parts by the passage of large 
fecal masses, which cause minute lacerations of the mucous membrane 
within the anal ring. Under a good light, gentle separation of the 
buttocks will usually bring the laceration into view. 

Symptoms. — There are few more painful affections. The vigorous 
crying preceding and during the defecations aids the mother in locat- 
ing the source of the child 's trouble. Occasionally the fecal mass will 
be streaked with blood. The constipation which causes the trouble 
is aggravated by the painful nature of the condition, as the child soon 
learns to dread an evacuation, and postpones the act until medication 
or some manipulative means is employed to induce a movement. 

Illustrative Case. — A little girl, twenty months old, was brought to me because 
she cried and objected to being placed in position for a bowel evacuation, and cried 
even more during the evacuation. On the day preceding the visit to my office the 
mother feared the child would have a convulsion, so great was her distress. Ex- 
amination of the rectum showed two rather small fissures extending, through the 
anal mucous membrane. 



PROCTITIS 261 

Treatment. — Diet. — For a prompt repair of the fissures it is 
necessary to render the stools soft. This, in the bottle-fed, is often 
easily accomplished by the addition to each feeding, of one or two 
teaspoonfuls of one of the malted foods, such as Mellin 's food or malted 
milk. In other instances one feeding of malted milk each day may 
be substituted for one of the regular feedings, in the strength of 4 to 6 
teaspoonfuls in 8 ounces of water. 

Drugs. — If drugs are necessary or are preferred, the addition of 2 
teaspoonfuls daily of the milk of magnesia to the milk food will prove 
of value. A teaspoonful of sweet oil after two or more feedings will 
likewise usually have the desired softening effect upon the stool. 

Local Measures. — Proper regulation of the bowel function, while 
absolutely necessary for a cure of the laceration, is not of itseK sufficient 
to effect permanent relief. The parts must be thoroughly washed 
with warm water and Castile soap after each defecation. After the 
washings, and at three-hour intervals during the day, 25 per cent, of 
ichthyol-aromonium-sulphate in zinc ointment should be applied with 
a clean index-finger, which is introduced well up into the anal aperture. 
If the fissure is deep, the treatment should be begun by cocainizing 
the parts with a 3 per cent, solution of cocain. The fissure may then 
be cauterized with a 50 per cent, solution of nitrate of silver, appHed 
on a cotton-tipped probe. Twelve hours later the ichthyol ointment 
may be used as in the milder cases. I have yet to see a case which does 
not respond to the above treatment if it is faithfully carried out. 

PROCTITIS 

Infiammations of the rectum are of three different forms — catarrhal, 
croupous or membranous, and ulcerative. 

Catarrhal proctitis is usually associated with a colitis higher in the 
bowel. When confined to the rectum, the process may be due to the 
careless use of irrigations or irritating suppositories, or the activity of 
thread- worms. 

The mucous membrane is red and swollen, and exudes not only 
mucus, but a small amount of blood. In gonorrheal proctitis, which 
occasionally complicates a vulvovaginal infection b}^ the same organ- 
ism, the discharge from the inflamed parts is characteristically 
purulent. 

Membranous proctitis may result from diphtheria of the genitals 
or from a local streptococcus infection. The morbid lesions closely 
resemble those of membranous colitis, and are not essentially different 
from those which occur in membranous inflammations of the throat. 
The grayish, organized exudate may be visible on the mucosa of the 
prolapsed bowel, or appear in fragments in the stools. 

Ulcerative proctitis is usually secondary to a severe catarrhal proc- 
titis, in which case the lesions tend to remain superficial. Follicular 
ulcers of greater depth may occur in connection with follicular colitis. 
Syphilitic and tuberculous ulcerations of the rectum are rare. Holt 



262 THE PRACTICE OF PEDIATRICS 

reports one case of the tuberculous type, and records Steffen 's obser- 
vations of three others. 

Symptoms. — In all forms of proctitis the movements of the bowels 
are frequent, and associated with tenesmus and the discharge of 
mucus and small amounts of blood. Prolapsus recti is not uncommon, 
and after reduction, shows a strong tendency to recur so long as the 
severe peristaltic activity of the bowel persists. The character of the 
discharge is of value in differentiating the existing type of inflammation. 

Treatment. — In mild cases of the catarrhal form injections of warm 
starch solution, alkaline liquid antiseptics, or sweet oil will effect a 
cure, provided the primary cause of the irritation has been removed. 
When the process is diphtheric, antitoxin should be promptly adminis- 
tered, as in cases of laryngeal diphtheria. 

Ulcerative proctitis requires especial care involving the use of 
cleansing irrigations and suppositories of tannigen, belladonna, opium, 
or cocain, combined with local application, at intervals, of a solution 
of silver nitrate of 0.2 to 0.5 per cent, strength. For the gonorrheal 
cases Koplik advises rectal injections of 2 per cent, protargol solution, 
at a temperature of 105° to 108°F., twice daily. 

ISCHIORECTAL ABSCESS 

An abscess of this nature is the result of a preceding adenitis of the 
lymph-glands in the neighborhood of the rectum. 

Symptoms. — The first sign will be that of pain on defecation or 
upon manipulation. Upon examination an oval, indurated mass will 
be found under the skin, usually not deeply placed. Much pain is evi- 
denced during the examination. In most instances there will be red- 
ness of the skin over the involved gland. Rarely can fluctuation be 
made out by palpation. Suppuration, however, follows the primary 
infection very rapidly, and a distinct area of reddened and inflamed 
skin indicates the presence of pus beneath. Children's hospitals, 
children 's asylums, and dispensary services supply the majority of these 
patients. Occasionally a case is seen in private work. 

Treatment. — All that is required is a free incision, daily washing- 
out of the abscess cavity with a 3 per cent, solution of hydrogen peroxid, 
and packing with sterilized gauze moistened with a saturated solution 
of boric acid. A layer of gauze, covered with oiled silk, should cover 
the dressing, to protect the wound from further infection by the fecal 
discharges. In case the granulations are sluggish, as they may be in 
marasmic infants, the gauze used for the packing may be saturated with 
the balsam of Peru. 



Vn. THE SPLEEN AND THE LIVER 
The Spleen 

In children the spleen is very rarely the seat of primary disease. 
Sarcoma, carcinoma, abscess, and cysts, with primary involvement of 
the spleen, have been reported. This organ, however, frequently shows 
secondary involvement and furnishes an important diagnostic sign in 
a large number of diseases. Thus the spleen is enlarged in syphilis, 
in rachitis, typhoid fever, in persistent intestinal infections, in malaria, 
in cirrhosis of the liver, in right heart failure, and in practically all the 
blood diseases of early life. 

Usually the organ shows a simple enlargement, which subsides 
when the disease causing the condition is removed. As the result of 
repeated or persistent enlargement for a considerable time, as in malaria 
and some of the blood disorders, it undergoes hyperplasia and per- 
manent enlargement. 

SPLENOMEGALY 

Primary splenomegaly of the Gaucher type is of unknown origin. 
The probable cause is a chronic toxic agent, to which a family predis- 
position exists. 

Splenomegaly in infantile splenic anemia has been found to be 
associated with a parasite, Leishmania infantum, similar to the Liesh- 
man-Donovan parasite, which is the cause of kala-azar. The parasite 
was discovered in the infantile cases by Pianese and Nicolle. 

Splenomegaly occurs in cases of septicemia, malaria, tuberculosis, 
syphilis, rachitis, leukemia, Hodgkin's disease, and anemia infantum 
pseudoleukaemia. In pernicious anemia the spleen is rarely very 
large. 

Neoplasms (sarcoma, angioma, fibroma, cysts) of the spleen are 
very rare. 

Obstruction of the portal circulation may cause splenomegaly, as 
in cirrhosis of the liver, heart disease, or pressure from a new-growth. 

The Liver 

The liver in infants and children is very rarely the seat of primary 
disease. In the mortality of childhood, as an immediate cause of fatal 
diseases the liver plays a very unimportant role. 

Derangement of function, on the other hand is unquestionably 
at the bottom of many disorders not at all understood at the present 
time. 

263 



264 THE PRACTICE OF PEDIATRICS 

Fatty change in the liver in early life is often found at autopsy. 
It is found in greater or less degree in practically all infants and young 
children who die from prolonged and exhausting diseases. 

Presumably the infiltration is of a temporary nature, and, so far 
as is known, has no symptomatology of its own. In many cases that 
recover the liver must have undergone fatty changes. It is rare not 
to find more or less fatty changes at a postmortem examination of a 
child under one year of age. In some cases the involvement is so ex- 
tensive that the entire organ is firm, smooth, and of a yellowish color. 
In other cases there are only localized evidences of the fatty process. 
Usually the organ is not enlarged. The condition is not to be diagnosed 
during life. If there is a derangement of function, this is not of such a 
nature as to make the actual hepatic conditions manifest. 

Acute Yellow Atrophy. — Fatal cases of this disease in children are 
reported at rare intervals. 

Abscess of the liver in the newly born is the result of an infection 
usually acquired from the umbilical veins. Several cases have been 
reported in literature, in which the abscess was caused by the migration 
of round-worms into the hepatic duct in older children. 

Abscess of the liver may result in any pyemic condition. Its rare 
occurrence demonstrates the hepatic powers of resistance against 
microbic invasion. 

The Amoeba coli has been the cause in a considerable number 
of cases. 

Symptoms. — Enlargement of the organ, associated with the pres- 
-ence of marked tenderness, is usual. Pain is a very constant symptom, 
and may be referred to different points in the abdomen. Not infre- 
quently it is felt at the umbilicus, or it may be localized between the 
right scapula and spine. Among the most prominent active manifes- 
tations, are repeated chills, a widely ranging septic temperature, and 
vomiting. Occasionally there is diarrhea. 

Exploration should be performed, and if pus is located, aspiration 
and drainage should follow. Abscesses not operated upon are apt to 
perforate into the peritoneal or pleural cavity. Cases of perforation 
into the intestine have been followed by recovery. 

Cirrhosis of the Liver. — Cirrhosis of the liver belongs to the curiosi- 
ties of pediatric practice. All the cases reported represent the obser- 
vations of as many men. 

In the reported cases in which there has been a supposed etiologic 
factor, syphihs, alcohol, and the infectious diseases have been looked 
upon as the agencies causing the disease. 

Toxic substances of widely different character are apparently capa- 
ble of causing cirrhosis of the liver in the young. 

' Symptoms. — At first there is enlargement of the liver and the spleen. 
Persistent but not severe icterus and ascites supervene. The patient 
shows early evidences of malnutrition, and a cachexia that is strongly 
suggestive of the underlying condition. As the case progresses the 
liver becomes very much reduced in size, diarrhea becomes fairly con- 



ICTERUS (obstructive JAUNDICE; CATARRHAL JAUNDICE) 265 

stant, vomiting frequent, and dilatation of the superficial abdominal 
veins occurs. Bronchopneumonia is the usual terminal complication. 
Treatment. — The management is entirely symptomatic. Tapping 
may temporarily relieve the embarrassed respiration and the general 
discomfort occasioned by the large amount of fluid in the abdominal 
cavity. 

ICTERUS (OBSTRUCTIVE JAUNDICE; CATARRHAL JAUNDICE) 

Jaundice of this type in children is usually associated with duoden- 
itis, and is caused by a swelling of the lymphoid bodies in the mucous 
membrane of the common bile-duct at its terminal opening into the 
intestine. The jaundice is due probably to the same form of infection 
that caused the duodenitis. Cases often occur in groups of two or three 
in the same family. In November, 1911, three children and two adults 
— the mother and nurse — had pronounced jaundice with the usual 
manifestations. Six weeks before, all these people had suffered from 
malaria. I have seen but one case in which jaundice was due to 
cholelithiasis. This patient, a girl six years of age, had distinct at- 
tacks of biliary colic, accompanied by passage of gall-stones and fol- 
lowed by intense jaundice. She was eventually operated upon and 
many stones were removed from the gall-bladder. 

Symptoms. — The onset of my cases has almost never been marked 
by high temperature or evidence of severe gastric disturbance. Usually 
the first signs have been loss of appetite, coated tongue, rise of a de- 
gree or two in temperature, and Hstlessness. The yellow discoloration 
of the conjunctiva and skin soon appears, and this, with the high- 
colored urine and slightly colored or grayish stools, makes the case 
complete. 

The liver is usually enlarged an inch or two below the ribs, and 
often is slightly tender. The spleen is also slightly enlarged. 

I have never known a fatal case, although such have been reported. 

Vomiting. — In my most severe case the vomiting continued for 
five days, neither food nor water being retained. Vomiting is present 
in most cases. The child vomits two to three times, or at intervals 
for a day or two. 

Treatment. — Diet. — The reason why gastric disorder is considered 
so prominent a symptom by many writers is possibly because of the 
gastric disturbance produced by the treatment. We are advised 
to place the patient on a milk diet and give calomel. I know of no 
treatment better calculated to produce vomiting and increase both 
the intestinal infection and the jaundice. The treatment which I 
have found most satisfactory is the use of very little food for twenty- 
four hours. Water is given as a drink, and later, well-salted chicken 
or mutton broth may be given with toast, if the child asks for food. 
He should not be urged to eat. The following day broths, gruels, and 
orange-juice, with stewed fruits or lemonade, are given if wanted. 

Drugs. — The only medication used consists of rhubarb and soda. 



266 THE PRACTICE OF PEDIATRICS 

To a child five years of age I give 4 grains of pulverized rhubarb and 8 
grains of bicarbonate of soda from two to three times daily, giving at 
the same time considerable water. For a day or two sufficient medi- 
cine should be given to produce a free laxative effect, but not nec- 
essarily enough to purge the patient. Usually on the third day I 
begin with tincture of nux vomica and dilute hydrochloric acid — from 
2 to 4 drops of each, well diluted. When the stools are again normal, 
the usual diet may be resumed, milk not being used for a week after- 
ward. Rhubarb and soda are best given as follows: 

I^ Pulveris rhei gr. xlviij 

Sodii bicarbonatis. gr. xcvj 

Syrupi rhei aromatici § | 

Aquae : q. s. ad § ij 

M. Sig. — Shake well. One teaspoonful two or three times daily after 
meals. 



VIIL DISEASES OF THE RESPIRATORY TRACT 

The Nose and Throat 
acute rhinitis (coryza; snuffles; cold in the head) 

Acute rhinitis is a very common ailment throughout childhood. 
Newly born babes, " runabouts," and school-children alike are suffer- 
ers. The so-called cold in the head is unquestionably an infection and 
may be transmitted from the diseased to the well. That a species 
of microorganism has not been demonstrated in no way invalidates 
this statement. I have time and again seen an acute rhinitis develop 
in one member of a family and pass through the entire household 
of perhaps six or eight persons, adults and children. Infants and 
young children should not come in contact with other persons suffering 
from acute rhinitis. 

Symptoms. — The onset is usually sudden, and characterized by 
sneezing and difficulty in breathing through the nose. This may 
continue for a few hours or, in some cases, for a day or two. At the 
expiration of this time a mucous, watery nasal discharge appears. 
Infants are the greatest sufferers, owing to the fact that breathing, 
which has to be carried on largely through the mouth, is rendered dif- 
ficult, and nursing, in consequence, is frequently interrupted. A de- 
gree or two of fever may exist at the commencement of the attack, but 
any elevation of temperature, as a rule, lasts only a few hours. Neg- 
lected cases sometimes become infected with pyogenic bacteria (stap- 
phylococcus, pneumococcus, and streptococcus), in which event a 
troublesome purulent rhinitis results. In the majority of the neglected 
cases, and in some of those that are well treated, the rhinitis is the 
beginning of an infection of the mucous membrane, which involves 
successively the fauces, tonsils, larynx, and bronchi. Repeated attacks 
doubtless contribute to the production of adenoid growths in the naso- 
pharyngeal vault. Otitis media is not an infrequent outcome, par- 
ticularly if the child has adenoids. 

Differential Diagnosis. — Acute simple rhinitis is to be differen- 
tiated from specific rhinitis, which is one of the first manifestations 
of congenital syphilis. When due to syphilitic infection, the condition 
is uninfluenced by the usual treatment. There is no tendency for it 
to descend and involve the mucous membrane of the bronchi. The 
hoarseness of congenital syphilis is persistent and of gradual develop- 
ment. Furthermore, if the rhinitis is due to syphilis, other diagnos- 
tic signs are present or will soon appear. 

Measles almost invariably begins as an acute rhinitis. The accom- 
panying conjunctivitis, the hard, dry, hacking cough, and the character- 
istic rash soon make the diagnosis possible. In nasal diphtheria there is 
invariably a discharge from the nose which may be differentiated from 

267 



268 THE PRACTICE OF PEDIATRICS 

that of simple rhinitis by the fact that the discharge in diphtheria i& 
excoriating in character and is often tinged with blood. A diphtheric 
discharge may be limited entirely to one nostril or may be greater 
from one nostril than the other; while in acute simple rhinitis the 
amount of the discharge is usually the same from both sides. In- 
fluenza begins with sneezing and nasal discharge, serous in character. 
In influenza, however, there will be associated cough, fever, and more 
or less prostration. 

Duration. — The tendency of acute simple rhinitis in a strong 
child is toward recovery in five or six days. When the surroundings 
are unfavorable, or the child is delicate or rachitic, active treatment 
will be required to bring about a prompt recovery. 

Complications. — Simple rhinitis is very often the beginning of an 
infection which may reach the middle ear and produce purulent otitis 
or mastoid disease. Cervical adenitis is not an infrequent outcome. 
Retropharyngeal adenitis and retropharyngeal abscess, acute laryngi- 
tis, bronchitis, and bronchopneumonia, may all result from acute 
rhinitis. Early treatment and care of the primary condition are, there- 
fore, exceedingly important. 

Treatment. — The first step is the administration of two teaspoon- 
fuls of castor oil. During the initial stage of engorgement much may 
be accomplished for the very young by local medicaments. One of the 
best is menthol, J-^ grain, dissolved in 1 ounce of liquid albolene. Of 
this solution 3 drops should be instilled into each nostril every hour 
by means of a medicine-dropper. This treatment alone will relieve 
the patient of distressing obstruction and facilitate freer breathing. 
Older children rnay use a spray containing 1 grain of menthol to 1 
ounce of liquid albolene at intervals of two or three hours. 

In case menthol and albolene are not at hand, melted white vaselin 
may be similarly employed. 

For internal use the following medication has served me well: 

At least six doses should be given in the twenty-four hours. 
For a child three months of age : 

I^ Tincturse belladonnae gtt. vij 

Pulveris camphorse gr. iv 

Sacchari lactis, q. s. 

M. div. et ft. tabellse no. xxx. 

Sig. — One tablet every two hours. 

Six months of age: 

I^ Tincturse belladonnse gtt. x 

Pulveris camphorse gr. y 

Pulveris ipecacuanhse et opii gr. iv 

Sacchari lactis, q. s. 

M. div. et ft. tabellse no. xxx. 

Sig. — One every two hours in water. 

From one to two years of age : 

I^ Tincturse belladonna? gtt. xv 

Pulveris camphorse gr. vj 

Pulveris ipecacuanhse et opii gr. x 

M. div. et ft. tabellse no. xxx. 

Sig. — One every two hours. 



CHRONIC RHINITIS (nASAL CATARRH) 269 

Prom two to four years of age: 

I^ Tincturae belladonnae gtt. xv 

Pulveris camphorae gr- vj 

Pulveris ipecacuanhse et opii gr. xv 

Sacchari lactis, q. s. 

M. div. et ft. tabellae no. xxx. 

Sig, — One every two hours. 

If for any reason the tablets cannot be prepared, powders will 
answer the purpose equally well. 

The above prescriptions are indicated for the second or catarrhal 
stage, in which we usually find the patient on beginning treatment. 
We must guard against the constipating effects of the camphor and 
the Dover's powder. 

In the treatment of nasal disorders the forcible use of the syringe, 
or any form of nasal irrigation which requires force, should be con- 
demned. Infection is easily carried into the Eustachian tubes, and may 
give rise to very grave complications. A suppurative otitis is thus 
very easily produced. 

An enema of warm sweet oil or soapsuds should be administered 
if the bowels do not move once in twenty-four hours. In treating chil- 
dren of a markedly constipated habit the Dover's powder may be 
omitted. Internal medication, if begun early and properly carried out, 
will not be needed for more than two or three days. During an 
attack of acute rhinitis the child should not be unnecessarily exposed 
to cold, owing to the strong tendency of the inflammation to descend 
and involve the deeper portion of the respiratory tract. 

CHRONIC RHINITIS (NASAL CATARRH) 

Nasal discharge, more or less constant, is present in not a few in- 
dividuals throughout childhood. In the majority of those affected 
this discharge begins with the onset of cold weather and lasts until 
spring. The secretion may be composed of thin, watery mucus, or it 
may be mucopurulent in character. 

Etiology. — In order to treat this condition successfully the source 
of the discharge must be discovered. It may be due to several causes, 
which are here given in the order of their frequency * 

1 . Adenoids in the nasopharyngeal vault. 

2. Hypertrophy of the turbinated bones, with septal deviations 
and hypertrophy of the mucous membranes. 

3. Infection due to pyogenic bacteria. When present, this may 
follow acute rhinitis, but is more often the sequel of one of the infectious 
diseases. The discharge may be distinctly purulent and is often very 
profuse. 

4. Infection due to the Klebs-Loffler bacillus. I have seen a great 
many cases of this type in children under eight years of age, in 
whom a serous discharge from one or both nostrils has persisted for a 
considerable period of time — in one instance for an entire year. Ex- 
amination of the discharge showed the presence of the Klebs-Loffler 



270 THE PRACTICE OF PEDIATRICS 

bacillus. Such children are not ill, and are brought to a physician 
solely for treatment of the nasal discharge. The cases do not clear up 
under ordinary methods of treatment, but promptly respond when 
from 1500 to 2000 units of diphtheria antitoxin is given. 

5. Hay-fever is characterized by a periodic discharge which may be 
said to be chronic in character, persisting over several weeks. 

6. Malnutrition. A thin, watery discharge, apparently due to 
relaxed mucous membranes, occurs in weak and poorly nourished 
children with no other abnormal condition to explain the trouble than 
the general weakness. 

7. Disease of the sinuses. Sinus infection of a mild type may 
cause persistent rhinitis without other symptoms, and these cavities 
should be examined in obscure cases. 

8. Foreign bodies. A foreign body in either nostril will produce 
a persistent discharge. When a child is brought to me with a history 
of a persistent serous or purulent discharge from one nostril, I invariably 
examine for a foreign body, and repeatedly have found this discharge 
explained by the presence of a pea, a bean, a piece of coal, or a button. 
At the out-patient department of the Babies' Hospital a child three 
years of age was brought for treatment of a persistent right-sided nasal 
discharge which had existed for seven months. Examination showed 
a foreign body well up in the nostril. This object was removed with 
considerable difficulty and proved to be a piece of cork. 

In these cases of chronic rhinitis the possibility of adenoids (see p. 
293) should never be forgotten; for their existence cannot be excluded 
because a child is not a mouth-breather and does not snore. A child 
with a chronic ''cold in the head" almost invariably has adenoid 
vegetations in the nasopharyngeal vault. Examination may reveal 
that the nasopharyngeal space is blocked by the growth, so that entrance 
with the finger is almost impossible. In other instances only a small, 
pulpy mass will be found, or a ridge of soft, friable growth at the upper 
portion of the vault, not large enough to produce signs of obstruction, 
but actively secreting and manifestly the source of the discharge. 
Children who have anterior nasal defects, such as hypertrophies of 
bone or thickening of the membranes, usually have adenoids as well. 
In fact, adenoids play no small part in most of the catarrhal affections 
of the upper respiratory tract in children, and an examination of a 
child with a nasal discharge or a cough which is difficult to explain 
is never complete without an exploration of the nasopharyngeal vault. 

Treatment. — The treatment consists in correcting the condition 
which causes the discharge. If adenoids are present in a sufficient 
amount to cause trouble, they should be removed (p. 298). No other 
treatment is of any avail. For deformities and hypertrophies of the 
anterior nasal structure operative measures are also essential, but 
should be carried out by one skilled in rhinoplastic work. Purulent 
rhinitis, primary or following the infectious diseases, is best treated 
by a spray composed of liquid albolene, 1 ounce, ichthyol ammonium 
sulphate, 2 grains, which should be thoroughly shaken before using. 



THROAT EXAMINATION 271 

This spray should be used every two hours while the child is awake. 
Once or twice a day it may be well, if the secretion is profuse and puru- 
lent, to instil into the nostril about 20 minims of a 1 : 6 aqueous solution 
of hydrogen peroxid. If the Klebs-Loffler bacillus is present, antitoxin 
alone will control the disease, and that very promptly. 

The anemic and poorly nourished patients, who show almost no ab- 
normahty, but suffer more or less from a constant serous discharge, 
are benefited by constitutional measures only — a dry climate, plain, 
nourishing food, iron, cod-liver oil, massage, and salt baths. Suitable 
management is referred to in detail under The Management of Delicate 
Children (p. 122). Applied to these children, local treatment, apart 
from cleanliness, is a loss of time and energy, 

NASAL HEMORRHAGE 

Non-traumatic nasal hemorrhage in a child usually occurs from one 
of two sources — adenoid vegetations in the nasopharyngeal vault or 
an erosion or ulceration of the mucous membrane covering the free 
vascular area of the anterior portion of the nasal septum. 

Treatment. — When the hemorrhage is due to the adenoid growth, 
it is usually readily controlled by keeping the child in an upright 
position, or by the application of cold to the back of the neck — pref- 
erably by a piece of ice wrapped in a table napkin or by an ice-bag. 
When the hemorrhage is due to an erosion of the septum and pressure of 
the finger on the outer side of the bleeding nostril is found ineffective, 
the nostril may be packed with cotton saturated with a 5 per cent, 
solution of antipyrin or a 1 :2000 solution of adrenalin. 

For permanent relief, and to prevent a recurrence of the hem- 
orrhage, adenoids should be removed and an excoriated or ulcerated 
septum cauterized with a 50 per cent, solution of silver nitrate. If 
the ulcer is first cleaned with plain water, ordinarily but one or two 
apphcations of the silver solution will be required. Spraying the 
affected side with a 1 per cent, solution of ichthyol in liquid albolene 
will hasten the healing process. As the ichthyol is not soluble in the 
oil, the mixture should be well shaken before using. 

THROAT EXAMINATION 

In order to examine the throat of a young child quickly and thor- 
oughly it is necessary that he be held in a proper position in front of 
and at the right side of the attendant, supported by her left arm 
beneath the buttocks. Her right arm, which is thus left free, is passed 
around the child, binding his arms to his sides. The child's head 
rests against the shoulder of the attendant. The physician places 
his left hand on the child's head to steady it, and with the tongue- 
depressor or teaspoon in his right hand, with the child in perfect control, 
presses the tongue downward so that it will not obscure the field of 
vision. In handling an older and stronger child, it is best to bind the 



^72 THE PRACTICE OF PEDIATRICS 

arms to the sides with a large towel or small sheet. The most satis- 
factory view can be obtained by daylight before a window. If the 
examination is made in the evening, a lamp or taper held by a third 
person, a little above and behind the attendant 's right shoulder, will 
furnish satisfactory illumination. The head-mirror should be used for 
children who are too ill to be taken out of bed, the reflection from a 
lighted lamp or candle being sufficient. The various electrical devices 
which may be carried in the pocket are very useful in throat examina- 
tion of children. 

PERSISTENT COUGH 

I have had occasion to examine and treat many children who 
were brought to me because of a '* cough " which had not been controlled 
by the measures employed. The history is usually only that of a per- 
sistent cough. This may be irritating in character, keeping the child 
awake at night, or it may be paroxysmal, the attacks being more severe 
when the child is lying down. Many times the paroxysms are so severe, 
particularly at night, that whooping-cough is suspected because of the 
absence of chest signs. 

Types of Cough. — While we hear much of the cough of teething, 
the ''stomach cough,'^ the ''nervous cough," and the "habit cough," 
it has never been my lot to see a case in which the cough was not con- 
nected in some way with the respiratory tract. Thorough examination 
of these cases, perhaps repeated examinations, will be required before 
the site of the trouble is definitely located, when it will invariably be 
found somewhere between the anterior nares and the thorax. The 
^'stomach cough," the "nervous cough," or the "teething cough" for- 
merly stood for the persistent cough which could not be accounted 
for by physical examination of the chest or by mere inspection of the 
throat. They are frequently referred to by the older writers. 

An adherent pleura and enlarged tonsils without adenoids are ac- 
countable for a very small number of these cases. An elongated 
uvula, to which these obscure coughs have also been attributed, is 
very rarely a cause. 

Adenoid Vegetations. — An immense majority of these obscure coughs 
in children are due to adenoid vegetations, with or without enlarged 
tonsils. A child with such a cough may have the typical adenoid face, 
mouth-breathing, and other signs referred to (see Adenoids, page 293), 
or these symptoms may be entirely absent. It is the latter type 
of case that is particularly puzzling and apt to be overlooked. On 
account of the absence of mouth-breathing and other symptoms of 
nasal obstruction, the possibility of adenoid vegetations has been 
ignored. In these cases careful inquiry will usually elicit the his- 
tory of frequent colds, or what is styled "catarrh" (as there is more 
or less serous discharge from the nose) , or the statement that the child 
' 'takes cold in the head easily. ' ' Digital examination of the nasopharyn- 
geal vault will reveal a fringe of soft adenoid growth at the upper 
portion of the posterior pharyngeal wall, not large enough to pro- 



FAUCITIS 273 

duce obstruction, but actively secreting. This secretion, if not profuse, 
is partially evaporated in the nostrils, or if profuse, is discharged from 
the nostrils or passes backward over the posterior pharyngeal wall, 
thus provoking cough, when the child is up and about. When the 
child rests on his back, the secretion naturally flows over the posterior 
pharyngeal wall, and induces cough. Time and again I have relieved 
the most obstinate cough by cureting and removing this sponge- 
like tissue. 

Illustrative Case, — In the case of one patient, a boy two years of age, who had 
been coughing hard for ten days with paroxysms and vomiting, a diagnosis of 
pertussis had been made both by a member of the family who had seen many cases 
of whooping-cough, and also by myself. Adenoids were found to be present in a 
slight degree. Their removal was accomplished, with the idea of making the 
coughing attacks less severe, when, greatly to our surprise, the coughing ceased 
at once, not a paroxysm occurring after the growth was removed. The cough was 
due to the adenoid vegetations and not to pertussis. 

Adherent Pleura. — Adherent pleura, non-tuberculous, as previously 
mentioned, is occasionally a cause of persistent cough. Autopsies upon 
children who have died with non-respiratory diseases often show these 
pleuritic adhesions, which are not suspected during life. A little girl 
twelve years of age was brought to me because of a persistent cough. 
The child was otherwise well and gaining in weight. She had been 
treated with expectorants, cod-liver oil, and the usual other medication, 
without avail. The cough remained unchanged and was influenced 
only by opiates. A very careful physical examination revealed friction 
rales, covering an area the size of a half-dollar, at the base of the right 
lung, adjacent to the spine. They were heard only on forced inspiration 
and had been overlooked in the previous examination. The case had 
been diagnosed as one of ''nervous cough." 

Tracheal Cough. — Tracheitis will produce a severe and intract- 
able cough, with no signs in the chest. These cases frequently follow 
attacks of true influenza, or the cough may be present during the 
active period of the disease. If the child is old enough, he will aid 
us by referring to the sense of discomfort and tightness, which exists 
over the upper portion of the chest. Sometimes the sensation will 
be described as a burning which is located directly over the trachea. 

Tuberculosis. — Incipient tuberculous infiltration in any portion of 
the lungs or pleura may produce persistent cough. Thorough physical 
examinations and careful observation of all the cases, with the von 
Pirquet test, will make a diagnosis possible. 

Pertussis. — Pertussis without the whoop or vomiting may cause a 
persistent cough, spasmodic in character. It runs its course and sub- 
sides in from four to eight weeks. A diagnosis is possible only when 
there is a history of exposure to the disease, or when another member 
of the family has an unquestionable attack. The treatment of the 
various conditions producing cough is referred to under their respective 
headings. 

FAUCITIS 

By the term, faucitis, we understand an inflammation of that por- 
tion of the mucous membrane of the buccal cavity situated posteriorly 
18 



274 THE PRACTICE OF PEDIATRICS 

to the soft palate and the anterior pillars of the fauces, including 
both the anterior and posterior pillars, the tonsils, and the pharyngeal 
vault. The inflammatory process is superficial, involving the mucous 
membrane only, so that the tonsils are involved only to the extent 
of the mucous membrane. 

Faucitis is always present in scarlet fever, usually to a marked 
degree. In measles it is also present, but less intense in its mani- 
festations. Its most frequent appearance is in connection with a sum- 
mer cold. Every year, in late May and June, I am called upon to treat 
a great many such cases. The symptoms always comprise cough, 
which is dry and ineffective, and a sKght fever — from 100° to 101°F. 
The child complains of sore throat, and has some discomfort on swal- 
lowing. Upon inspection, an intense inflammation will be noticed, 
involving the entire visible mucous membrane. In many cases the 
inflammation extends downward and involves the larynx, which fact 
will be indicated by the hoarse, croupy character of the cough. The 
condition is usually the result of a mixed infection, with the strepto- 
coccus predominant. The entire illness is ordinarily of three or four 
days' duration. 

Treatment. — The condition is best relieved by a purgative of rhu- 
barb and soda — 3 grains of powdered rhubarb and 3 grains of soda for 
a child from two to five years of age. To a child under two years 
of age 1 to 3 grains of rhubarb and 1 to 2 grains of bicarbonate of soda 
may be given. This, in the case of a child from one to three years of 
age, is followed by a tablet or powder of tartar emetic, J^^o grain, 
powdered ipecac, %o grain, and chlorate of potash, 1 grain, at two- 
hour intervals. Older children, three years and over, receive 2 to 3 
grains of chlorate of potash, 3^^o grain of tartar emetic, and 34o 
grain of ipecac at two-hour intervals — 6 doses in twenty-four hours. 

PHARYNGITIS 

Inflammation limited to the posterior pharyngeal wall is of rather 
infrequent occurrence in young children. When thus affected, the 
parts present a reddened, granular appearance. In the cases which 
have come under my observation such a condition has always been 
associated with digestive disturbances. The tongue is usually coated, 
and the breath, foul. A dry cough and frequent attempts at clearing 
the throat are the usual symptoms. The temperature is rarely above 
101 °F. The condition is to be distinguished from the pharyngitis 
which occurs as a result of microbic infection, in that only the pos- 
terior wall is involved, the adjacent structures remaining unchanged. 
The tonsils and pillars of the fauces and the soft palate present a 
normal appearance. 

Treatment. — The treatment is to reduce the diet for a few days to 
cereal gruels, — barley, rice, or wheat, — or to chicken or mutton 
broth. Calomel, 3^o grain, with 1 grain of rhubarb, given after feed- 
ings, three times a day for three days, will promptly relieve the 
condition. 



ACUTE RETROPHARYNGEAL ABSCESS 275 

RETROPHARYNGEAL ADENITIS 

Retropharyngeal adenitis, as the name implies, is an inflammation 
of one or more of the glands situated posterior to the pharynx, between 
the pharyngeal and prevertebral muscles. 

Symptoms. — Pain and difficulty in swallowing are always present. 
Other symptoms are fever — 100° to 103°F. — and loss of appetite. The 
patient often holds the head toward the affected side, so as to relax the 
muscle tension caused by the tumor. If the adenitis is situated low 
down, disturbance of the voice (cracked voice) and respiratory obstruc- 
tion may result. 

Diagnosis. — In an acute case inspection of the throat will usually 
show a swelling at the right of the median line. If situated low down 
on the posterior pharyngeal wall, the adenitis may escape detection. 
Upon digital examination, instead of a smooth, flat surface, the finger 
encounters an elevated, rounded mass, which should not be mistaken 
for an unduly prominent cervical vertebra. 

Prognosis. — The glands, as a rule, suppurate, forming a retro- 
pharyngeal abscess. This, however, does not invariably follow. 
I have seen several cases in which the adenitis subsided without 
suppuration. 

Treatment. — The treatment must be both local and constitutional. 
Local treatment consists in cleanliness. The mouth should be washed 
with a saturated solution of boric acid after each feeding. lodids, 
in treating adenitis in children, I have found of questionable service. 
More is accomplished by suitable diet and plenty of fresh air. 

ACUTE RETROPHARYNGEAL ABSCESS 

Acute retropharyngeal abscess is the result of an infection of 
one or more of the retropharyngeal lymph-nodes which form a chain 
on either side of the median line, posterior to the pharynx, and be- 
tween the pharyngeal and the prevertebral muscles. 

Location. — The abscess is most frequently situated to the right of 
the median line. It may be located high in the pharynx, so as to be 
plainly visible when the mouth is well opened, or it may be placed low, 
posterior to the larynx and upper trachea. Usually the abscess points 
anteriorly into the throat. It may point both externally and internally. 
In a large number of cases I have not seen one that pointed externally 
only. 

Age of Patients. — Retropharyngeal abscess is preeminently a 
disease of infancy. The retropharyngeal lymph-nodes are said to 
disappear at the third year. I have not seen a case in a child over 
three years of age. 

Etiology. — Any active infection of the throat may cause the dis- 
ease. It may occur without our knowledge of any infectious process 
having been present. All throats continually harbor pathogenic 
bacteria, which may infect the retropharyngeal lymph-nodes. 



276 THE PRACTICE OF PEDIATRICS 

It has not been my observation that retropharyngeal abscess i-s 
a common sequel of diphtheria and the exanthemata. 

Symptoms. — I agree with Morse and others who state that these 
cases are usually overlooked — erroneously diagnosed. They are fre- 
quently diagnosed as cases of adenoids, and the removal operation is 
advised. It is a mistake to lay down too definite a symptomatology 
of a condition that lends itself to widely varying symptoms. In de- 
scribing the disease writers tell us that the patient holds the head in a 
characteristic position, — backward and toward the affected side, — 
that the breathing is noisy and stertorous in character, that there is 
difficulty in swallowing, that there are enlarged lymph-glands at the 
angle of the jaw, that there is usually a high fever, and that a bulging 
of one side of the posterior pharyngeal wall is usually visible. It is 
exceedingly rare to find this combination of symptoms. There are 
two diagnostic symptoms that are present in all cases — difficulty in 
swallowing and a persistently changed voice — a so-called cracked, high- 
pitched voice. These symptoms should lead one to suspect retro- 
pharyngeal adenitis or abscess, and the finger examination determines 
which condition is present. If adenitis exists, a rounded, hard tumor 
will be felt; if an abscess has formed, a soft, fluctuating tumor will be 
detected. This may be placed so high in the pharyngeal vault as to 
be plainly seen through a wide-open mouth, or it may be low and out of 
sight in ordinary examination. There is a variation of at least two 
inches in the possible location of the abscess, and this fact accounts for 
the varying symptomatology. The difficulty in swallowing interferes 
greatly with nursing, and should always lead the physician not only 
to inspection, but also to digital examination of the throat. 

Illustrative Cases. — A baby nine months of age had been under treatment in. 
one of the outdoor clinics of New York City. A diagnosis of adenoids had been 
made and a day appointed for the operation. The mother, wishing to have the 
diagnosis of adenoids confirmed, brought the child to the Babies' Hospital. The 
symptoms of mouth-breathing, nasal voice, and slight difficulty in swallowing had 
been present for a couple of weeks. There was no characteristic position of the 
head, no rigidity of the neck, no superficial enlargement of the lymphatic glands. 
Inspection of the throat disclosed a bulging forward of the soft palate on the right 
side. A digital examination revealed a round, fluctuating mass, the size of a 
hickory-nut. It was found high on the posterior pharyngeal wall and almost 
entirely covered by the soft palate. No adenoids were present. 

A baby two years of age had been ill for a week with tonsillar diphtheria and 
was thought to be recovering, when suddenly the voice became hoarse and croupy, 
with gradually increasing dyspnea. Both expiratory and inspiratory obstruction 
were present, such as we expect in laryngeal diphtheria, and the attending physician, 
an excellent practitioner, naturally concluded that the diphtheric process had 
extended to the larynx. There was stiffness of the neck but no nasal obstruction 
(see above). There was slight difficulty in swallowing. Inspection of the throat 
with a dim light revealed nothing but the enlarged tonsils. I was called to intubate, 
and finding the respiratory obstruction sufficient to require intubation, I pro- 
ceeded to make a digital examination, as is my custom before intubating. I 
w^as not a little surprised to find a soft, fluctuating mass low down in the pharyngeal 
wall, extending below and pressing against the glottis. The abscess was opened, 
with immediate relief to the obstruction. 

A baby, seven and a half months of age, was an inmate of the country branch of 
the New York Infant Asylum during my service in that institution.* My atten- 

* The case was reported at the time by Dr. Henry E. Tuley, assistant resident 
physician. 



ACUTE RETROPHARYNGEAL ABSCESS 277 

tion was first called to the child because of the difficulty in swallowing. There 
was very little obstruction, but the voice was harsh, hoarse, and croupy. About a 
month previous there had been a suppurating submaxillary adenitis. "^On examin- 
ing the throat, a large abscess was visible on the right pharyngeal wall, extending 
downward as far as could be seen. This case afforded my first experience with re- 
tropharyngeal abscess, and a Denhard gag of the O'Dwyer set, which should never 
be used in these cases, was introduced while the child was held in an upright posi- 
tion by the assistant. While I was feeUng for the thinnest point of the sac for a 
suitable place for the incision, the child suddenly stopped breathing, and became 
limp and apparently lifeless. An intubation tube, the smallest of the O'Dwyer 
set, was quickly introduced without the gag. After several minutes of artificial 
respiration, the use of oxygen, and free hypodermatic stimulation with brandy, 
respiration was again estabhshed. The first inspiration was so long delayed 
that we had almost given up the case as hopeless, when the first short gasp occurred. 
In half an hour the child had sufficiently recovered to allow the opening of the 
abscess. This was done without a gag, with the tube in position. After a copious 
discharge of pus, the tube was removed and the child recovered. In this case the 
suffocation was doubtless due to the introduction of the gag and the pressure of 
the finger, which forced the pus into the lower portion of the sac which extended 
below the glottis, where the pus exerted sufficient pressure to prevent the entrance 
of air. 

A private patient one year old had diphtheria-^laryngeal, faucial, and tonsillar. 
Under 9000 units of antitoxin and intubation satisfactory progress was made, and 
on the eighth day of the illness the tube was removed. It had to be replaced in a 
few minutes because of returning dyspnea. Upon replacing the tube an abscess 
was found in the right posterior pharyngeal wall, pressing upon and extending 
below the larynx. The presence of the tube had prevented the recognition of 
the abscess. Upon determination of the cause of the obstruction the abscess was 
evacuated, but the marked edema of the glottis still caused considerable respiratory 
obstruction, and the tube was required for two weeks longer. The child made a 
perfect recovery. 

The above cases are cited in detail in order that the reader may 
the more fully realize that retropharyngeal abscess may exist with- 
out the so-called "characteristic symptoms," and also to emphasize 
the fact that many cases have been, and will continue to be, over- 
looked until physicians use the finger as an aid to diagnosis in the 
diseases of the upper respiratory tract. It is to be remembered that 
there is no "characteristic breathing" and no "characteristic posi- 
tion" of the head with retropharyngeal abscess. The disease is 
usually secondary to retropharyngeal adenitis due to infection from 
adjacent diseased structures. Occasionally the abscess points outward 
and requires external incision. 

Fever. — There is no characteristic temperature: it may vary a 
degree or two, from the normal, or it may range high — from 103° to 
105°F. 

Treatment. — There is but one means of treatment — incision and 
evacuation of the pus. In order that this may be done it is neces- 
sary that the child be under perfect control. The arms should be bound 
to the sides with a large towel or a small sheet, securely pinned. The 
child is held in an upright position on the lap of the attendant, who 
passes his left arm around the child, while his right hand grasps the 
forehead, drawing the head for further support backward against his 
right shoulder. The operation should be performed in a good hght — 
either reflected light from a head-mirror or direct light from a window. 
With a tongue depressor in the operator's left hand holding the tongue 
out of the way, the mouth is kept open, and the right hand is free to 



278 THE PRACTICE OF PEDIATRICS 

make the incision, for which an ordinary scalpel is used. The posterior 
portion of the cutting surface should be guarded with adhesive 
plaster wrapped around the blade. The incision should be made 
from above downward, at least one-half inch in length. A basin 
should be in readiness and the attendant should be instructed to 
invert the child at a word from the operator as soon as the incision 
is made. This allows the pus and blood, which, if aspirated into the 
trachea, may produce fatal results, to stream out of the mouth. While 
the abscess is discharging and the head is dependent, the clean index- 
finger of the operator should explore the cavity, enlarge the opening, 
if necessary, and remove any necrotic tissue that may be present. The 
case should be carefully watched for several days, as the opening may 
close before resolution is complete, particularly if it has not been en- 
larged with the finger. Recovery is usually complete in from five 
to seven days. 

RETROPHARYNGEAL ABSCESS— TUBERCULOUS CARIES OF THE 
CERVICAL VERTEBRA 

This is usually wrongly described as associated with idiopathic 
retropharyngeal abscess. The tuberculous condition actually is a part 
of, and results from, tuberculous disease of the spine, which will be re- 
ferred to under the proper headings. 

IRRIGATION OF THE THROAT 

Indications. — In cases of peritonsillar abscess, retropharyngeal 
abscess after operation, or sloughing ulcerative processes in the throat, 
such as we see in diphtheria rarely, but with comparative frequency in 
scarlet fever, irrigation of the throat with hot normal salt solution 
is of distinct therapeutic value. The relief to the pain, particularly 
in quinsy before operation, is sufficient to warrant this treatment. 
Those who have thus treated the fetid, sloughing throat of scarlet fever, 
for example, need no argument as to the possible advantages. Gargling 
is a measure of very limited usefulness even for those children who do 
it well, for the reason that the solution employed scarcely comes in 
contact with the postpharyngeal wall and the lateral f aucial structures. 
For a great majority of older children, and all young children, such a 
method is practically useless so far as the cleansing of the deeper 
f aucial structures is concerned. 

Cervical adenitis, acute, persistent, and suppurative, is the direct 
result of throat infection. Acute suppurative otitis is always due to 
throat infection. An important means of preventing these conditions, 
with their distressing consequences, is an effective throat toilet. Often 
in scarlet fever not a small part of the systemic infection after the 
third or fourth day is through the throat. The irrigation should be 
done two or three times a day as follows: 

Operation. — The child is wrapped in a sheet, which is securely 
pinned, binding his arms to his sides. He rests on his right side, with- 



THE TONSILS 279 

out a pillow. Directly under his mouth is a pus-basin to catch the 
outflow. A new fountain-syringe, containing a hot salt solution, 120°F., 
is suspended about three feet above the child's body. The largest 
size of the hard-rubber rectal tip is fastened to the pipe and the tip is 
placed between the child 's teeth. The current, interrupted every few 
seconds, should be forcible enough to increase its efficacy as a cleansing 
agent, the volume of fluid being so small that no inspiration of the water 
occurs. 

The first irrigations will arouse more or less rebellion on the part 
of the patient, and but one-half pint of the solution need be used. 
With older children, no trouble will be experienced after the relief 
afforded by the first irrigation is appreciated. In treating refractory 
young children, from two or four years of age, the assurance that 
there will be no pain, and a promise of reward, will reduce the struggling 
to a minimum. It is not to be expected that the child will not cough; 
in fact, a moderate amount of coughing is desirable, as it dislodges the 
pus and sloughing tissue, allowing the solution to cleanse the parts 
more effectually. 

THE TONSILS 

Anatomically, the lymphoid structures in the pharynx, termed ton- 
sils, consist of several groups. Of these, the faucial and pharyngeal 
structures are clinically of most importance. 

. The faucial tonsils are situated one on each side of the oropharynx, 
between the anterior and posterior pillars of the fauces. The tonsil 
is roughly ovoid, and in early life about 2 cm. thick, the longest meas- 
urement being the vertical diameter. The inner surface presents many 
depressions or crypts. These are most numerous in the upper portion. 
Above the organ there is a larger depression called the supratonsillar 
fossa. This frequently serves as a pocket for the development of 
suppurative inflammation. On its outer surface the tonsil is covered 
by a fibrous capsule, from which the reticulum of connective tissue 
supporting the lymphoid structure is derived. In close relation to 
this surface is the ascending palatine artery. The internal and external 
carotid arteries are normally about 2 cm. distant, but as a result of 
inflammation and hypertrophy in the tonsils, these vessels may be less 
remote. Branches to the organs are derived chiefly from the ascending 
pharyngeal and facial arteries, but also from the lingual and descending 
palatine. Hemorrhage following operations arises principally from 
the ascending palatine, the ascending pharyngeal, and tonsillar branches 
of the facial. Operative wounds of the carotids are very rare. 

The pharyngeal tonsil is a single structure, occupying the posterior- 
pharyngeal wall. According to Piersol, without being markedly hyper- 
trophied, it may encroach upon the nasopharyngeal space. 

The tubal tonsils and the lingual tonsils are developed respectively 
at the Eustachian orifices and over the posterior third of the tongue. 
Scattered collections of the same tissue unite with the larger masses 



280 THE PRACTICE OF PEDIATRICS 

described, and form an irregular guardian-ring encircling the upper 
part of the pharynx. 

TONSILLITIS— ACUTE FOLLICULAR TONSILLITIS 

Tonsillitis consists in an inflammation of the mucous membrane 
and glandular structure of the tonsil. 

Age. — No age appears to be exempt. I have seen the condition 
in infants three or four weeks old. The great majority of the cases,, 
however, occur between the second and twelfth years. 

Etiology. — Tonsillitis is due to a mixed infection, with the strepto- 
coccus predominating. The disease is exceedingly infectious, and fre- 
quently occurs in epidemics. 

Predisposition. — One attack prediposes to another by preparing 
a suitable culture-field in the crypts. Children in whom lymphatism 
is prominent, and in whom the glandular structure possesses a poor 
resistance, are the most susceptible. 

Pathology. — The tonsils undergo considerable enlargement, and the 
crypts become filled with exudate consisting of epithelial detritus, mucus,, 
pus, and bacteria. Occasionally the exudate covers the surface of 
the organ in the form of a pseudomembrane similar in appearance to 
that occurring in diphtheria. The pathogenic bacteria most frequently 
present are the streptococcus, staphylococcus, and pneumococcus. 
Of these, the streptococcus is so frequently a cause of the inflammation 
that in many epidemics the term tonsillitis has been superseded by the 
convenient designation, ' 'streptococcus sore throat.^' When the cel- 
lular infiltration in the depths of the tonsil becomes extreme, sup- 
puration and abscess-formation, combined with severe edema of the 
peritonsillar tissue, is not uncommon. If the discharge of such a col- 
lection of pus is not spontaneous or else obtained by early incision, 
complete destruction of the parenchyma and the formation of a 
retropharyngeal abscess may result. 

Symptoms. — The onset of tonsillitis is usually sudden and may be 
attended by a chill. In a few of my cases an attack has been ushered 
in by convulsions. However, the usual mode of onset is with fever — 
101° to 103°F., lassitude, loss of appetite, and muscular soreness. 
Young children may show difficulty in swallowing, and older children 
may complain of pain in the throat. Not every case of tonsillitis, 
however, is characterized by the existence of such pain. Inspection 
shows that the tonsils are swollen and reddened and perhaps covered 
with scattered, light-colored, cheesy deposits. In some instances the 
local signs consist only of the swelling and redness; in other cases the 
cheesy deposit exists as an early manifestation. The spots of exudate 
may remain distinct and single, or they may coalesce, forming a 
pseudomembrane. During the attack the patient feels decidedly ill, 
and often gives evidence of considerable prostration. The tempera- 
ture ranges from lOS"" to 105°F. Slight swelling may occur in the 
lymphatic glands at the angle of the jaw, but this is usually absent. 



TONSILLITIS ACUTE FOLLICULAR TONSILLITIS 281 

In a comparatively small percentage of cases the associated adenitis 
will be very pronounced. A great deal of tenderness of the glands, 
with a sore throat, is a suspicious sign, and should lead one to ex- 
amine very carefully for diphtheria. 

Duration. — An uncomplicated attack of tonsillitis lasts from three 
to five days. If the temperature continues for a longer period than 
six days, the possibility of complications should be considered. 

Prognosis. — The prognosis is favorable; when uncomplicated, the 
disease is never fatal. 

Complications. — Cervical adenitis, otitis, peritonsillar (quinsy), and 
retropharyngeal abscess are the most frequent secondary conditions. 
Infrequent complications are endocarditis, pericarditis, and pyemia. 

Differential Diagnosis. — Tonsillitis must be differentiated from 
tonsillar diphtheria. There are few harder problems, and, in fact, in 
many cases, early in the attack, the solution is impossible without a 
bacteriologic examination. The following characteristics of the average 
case of each of the two diseases may aid us in differentiating : 

Tonsillitis. — Onset sudden; fever high at onset — 102° to 105°F. 
Glands at the angle of the jaw swollen slightly, if at all. Exudation, 
follicular, appearing as small dots; may form membrane through 
coalescence. 

Tonsillar Diphtheria. — Onset gradual; fever usually low at onset 
100° to 102°F. Lymphatic glands at the angle of the jaw considerably 
swollen. Membrane present on the tonsil appearing in thin, grayish 
layers which gradually become thicker and more extensive. 

Mixed Infection. — A case of mixed infection may at first present the 
picture of typical tonsillitis. The temperature may vary from 103° 
to 105°F. Pain upon swallowing, prostration, and loss of appetite 
may exist together with a follicular exudation. Such a case may remain 
stationary for twenty-four to forty-eight hours. The dots then coalesce, 
forming a firm membranous deposit; the lymph-nodes at the angle of 
the jaw enlarge; and, in short, both the clinical manifestations and 
the bacteriologic examination show that we have to deal with a case 
of diphtheria. 

These cases of diphtheria which are preceded by a clinical tonsillitis 
are probably the most dangerous. The primary condition is diagnosed 
as tonsillitis, and for several days is considered to be only a tonsilhtis, 
in spite of the membranous deposit which later forms. This delay in 
making the diagnosis gives abundant opportunity for the exposure of 
other children, and postpones the use of antitoxin, rendering the 
remedy, when finally given, of little or no avail. It is my rule to 
consider as diphtheric every case in which there is a pseudomembrane 
on the tonsils, and to treat such a case with antitoxin without waiting 
for a bacteriologic examination. Furthermore, when there are other 
children in the family, I invariably quarantine every case of simple 
tonsillitis. 

Treatment. — ^Local treatment of the diseased parts in tonsillitis by 
spraying, swabbing, and painting has been of very little service in 



282 THE PRACTICE OF PEDIATRICS 

my hands, particularly in dealing with children under four years of 
age. When the patient is held by force for such treatment, thorough- 
ness is impossible, and little or nothing is accomplished. For tract- 
able children and those old enough to understand what is being done, 
gargles, sprays, and irrigations are useful in so far as they relieve pain 
and cleanse the diseased parts. A useful gargle is the following: 

I^ Sodii salicylatis, • 

Sodii biboratis, 

Sodii bicarbonatis aa gr. xlv 

Essentise menthse piperitse 5 j 

Aquae q. s. ad g ij 

M. Sig, — One teaspoonful in one-half glass of water at 115 °F. Gargle 
entire quantity every hour. 

A useful spray is the following : 

I^ Acidi borici gr. Ix 

Aquae menthse piperitae 5 viij 

M. Sig. — Spray throat every two hours. 

Irrigation of the throat is indicated in tonsillitis not only for pur- 
poses of cleanliness, but because of the relief from pain which it affords. 
In severe tonsillitis associated with much swelling and consequent 
tension, the pain upon swallowing is often excruciating. For the irri- 
gation a fountain-syringe and a clean tube for introduction into the 
mouth are needed. The child may lie down or sit up. If the recum- 
bent position is maintained, the head should be turned to one side so 
that the mouth rests over a pus-basin, which catches the water as it 
passes out during the irrigation. If the irrigation be given with the 
patient sitting erect, a basin held under the chin will catch the water 
as it flows from the mouth. Two pints of normal salt solution — one 
teaspoonful of salt to a pint of water — at 115°F. is placed in the 
bag, which has previously been warmed. The bag is then held two 
feet above the child's head, and the solution is allowed to flow in a 
brisk stream against the swollen parts until at least one pint has been 
used. The irrigations, if found acceptable, may be repeated in from 
four to six hours. 

It is advisable to begin the general treatment with a laxative. One 
grain of calomel, in divided doses of 3-^ grain every hour, answers well. 
The food should be reduced. For a bottle-fed patient one-half the 
quantity of the usual milk mixture should be given, diluted with an 
equal quantity of water. The fever, if high, may be readily controlled 
by cool sponging. 

The only drug which has appeared to me to possess any signal value 
for internal use in tonsillitis is chlorate of potash given in the dosage of 
1 grain at two-hour intervals for a child one year of age; 2 grains at 
two-hour intervals for a child two years of age — 16 grains in twenty- 
four hours ; 3 grains at the same interval for a child three years of age — 
24 grains in twenty-four hours. I rarely give more than 3 grains at 
two-hour intervals at any age. I have used chlorate of potash in 
this way for several years, and I have never been able to associate 
its action with kidney complications in any of the hundreds of cases 



PERITONSILLAR ABSCESS (qUINSy) 



283 



in which I have used it. This drug is usually given in solution with 
simple elixir and water or syrup of raspberry and water. 

Children who have repeated attacks of tonsillitis should have the 
tonsils enucleated regardless of their size, as diseased tonsils are portals 
of infection and a source of ever-present danger. 

Cold compresses (see Fig. 26) applied to the throat are of aid to 
older children, who can appreciate the necessity of this measure. This 
form of treatment is described in detail under the management of acute 
catarrhal laryngitis. (See p. 290.) 



PERITONSILLAR ABSCESS (QUINSY) 

The seat of a peritonsillar abscess is in the cellular tissue about the 
tonsil, and the condition is due to an invasion of the parts by patho- 
genic bacteria, among 
which the streptococcus is 
most frequently present. 
The source of the infecting 
agent is almost invariably 
a tonsil more or less dis- 
eased. The abscess may 
form above, in front of, or 
behind the tonsil. The 
disease is seen rather infre- 
quently in children. I 
have known but one case 
in a child under six years 
of age. Quinsy is usually 
preceded by tonsilhtis. 
In none of my cases has 
the abscess followed diph- 
theria, scarlet fever, or 
measles. 

Symptoms. — The child 
has tonsillitis with the 
usual symptoms, and in 
addition, greatly increased 
swelling of the throat and 

pain upon swallowing. He complains of pain in the muscles of the neck 
on the affected side, and holds the head toward that side. A fairly early 
symptom is inability to open the mouth to the usual extent. In the 
average case inspection reveals a reddened, edematous swelling, slightly 
above and in front of the tonsil, causing a forward displacement of 
the uvula. In a few instances I have seen swelling develop behind 
the tonsil, in which case the tonsil on the affected side is displaced for- 
ward and appears unduly prominent. A case of this type is very apt 
to be overlooked unless a digital examination is carefully made, when a 
soft, fluctuating swelling will readily be felt behind the tonsil. Speech 




Fig. 




26. — Cold compress in position. 



284 THE PRACTICE OF PEDIATRICS 

is interfered with, and the act of swallowing is carried out with 
great discomfort. Young patients will go for several days with little 
or no nourishment because of the pain occasioned by the taking of food. 

Treatment. — The treatment is by incision. This step, however, 
should not be taken until the abscess is fully developed. If the inci- 
sion is made too early, it has in my cases invariably closed and required 
reopening. This closure sometimes occurs even after a timely opera- 
tion, because when too small an incision is made, the contraction of the 
abscess wall necessarily following the free discharge of pus and blood 
effectually closes the opening. 

For operation the patient should be wrapped in a large towel or 
sheet with the arms securely bound to the sides. He should sit in an 
upright position on the lap of the attendant, against whose right 
shoulder his head rests. The left arm of the attendant is passed around 
the patient, holding him firmly, while the right hand grasps his fore- 
head. A Denhard gag of the O'Dwyer set should be used to hold the 
mouth open. Either by the use of reflected light from a head-mirror, 
or with the patient facing a window, the operator, using a guarded 
bistoury, makes a free incision in the abscess from above downward. 
The escape of a considerable amount of blood usually follows the with- 
drawal of the knife. Oftentimes more blood than pus is discharged. 
This is particularly apt to be the case if the abscess is opened early. 

It is interesting to note that the cases which open spontaneously 
never heal spontaneously. After making a free incision it is my custom, 
during my daily visits immediately after the operation, to prevent a 
closure of the wound by passing into it a director, moving this up and 
down to break up any beginning granulations. With free, uninter- 
rupted drainage the case is usually well in from three to five days. 

With the exception of a saline laxative, which should be given early 
in the attack, internal medication is valueless. Two drams of Rochelle 
salts or 6 ounces of a solution of citrate of magnesia are usually ordered. 
Other treatment is directed to the comfort of the patient. An ice-bag 
applied externally before operation may be acceptable. Our greatest 
means of relief, however, is afforded by the use of the hot saline irriga- 
tion, and the hot gargle where practicable. But few children can 
gargle well, however, so that ordinarily this measure is best dispensed 
with. With the few cases where it is practicable, I have found the 
following prescription and method of use of service : 

I^ Sodii bicarbonatis gr. xlv 

Essentise menthse piperitiE 5 j 

Aquai q. s. ad Bij 

M. Sig. — Add 1 teaspoonful to 6 ounces of water at 120°F. and gargle 
entire quantity every half hour. 

The pain occasioned by gargling is another objection to its practice 
by children. A far more effectual means of relieving pain in this dis- 
ease, and one which causes no effort nor distress whatever, and which 
gives astonishing relief, is a saline irrigation which is prepared and 
given as follows : A heaping teaspoonful of salt is added to one pint 



Vincent's angina 285 

of water at 120°F. This is placed in a fountain syringe which is previ- 
ously warmed. A towel is placed around the patient's neck, to pro- 
tect the clothing. The basin is held under the mouth, to catch the 
drainage. With everything in readiness, the bag containing this 
solution being hung from two to three feet higher than the child 's head, 
the end of the rubber tube, a part of every fountain syringe, without the 
hard rubber tip attachment, is placed in the child 's mouth and the hot 
solution is allowed to flow against the inflamed surfaces until the entire 
pint has been used, pressure being maintained upon the tube so that 
the flow will not be too free. During the first irrigation or two, there 
will be more or less coughing, and the child may have to rest after an 
interval of a few minutes. After he becomes accustomed to the pro- 
cedure the entire pint may be used without intermission. The irriga- 
tion may be repeated every hour and may be used as well after as before 
operation. When once the child experiences the relief afforded, there 
will be no trouble in repeating the irrigation. 

VINCENT'S ANGINA 

In Vincent's angina there is an ulcer of the tonsil of varying size. 
It may involve the whole tonsil or a very small portion. The shape 
of the ulcer is irregular with overhanging edges in advanced cases, 
in appearance not unlike a syphilitic lesion. The ulcer is of varying 
depth, usually not more than a quarter of an inch at the deepest part. 
The sloughing bed of the ulcer gives the appearance of a membranous 
deposit. 

Etiology. — Vincent's angina is an infection in which two forms of 
parasites may be isolated, one a fusiform bacillus and the other a 
spirillum. They are always associated. These are also found in 
ulcerative stomatitis. 

The bacillus is a slender rod measuring from 6 to 12 /i long 
pointed at each end, gram negative, and is not motile. The spiril- 
lum generally has from 3 to 10 convolutions, is actively motile, and 
gram negative. These sometimes appear in a mixed infection with 
diphtheria. 

Symptoms. — The symptoms are not at all severe, usually a slight 
rise in temperature, 100 to 102 with perhaps moderate swelling of the 
lymph nodes on the affected side. There is often an accompanying 
stomatitis which may be the trouble for which the physician is con- 
sulted. That there is an involvement of the tonsil is first discovered 
during the examination of the patient. Very severe and fatal cases 
have been reported but these are surely very unusual. 

Diagnosis. — The case may resemble diphtheria sufficiently to 
require that a culture be made. A differential diagnosis is usually 
readily made by a microscopical examination of a smear from the ulcer. 
The bacilli and spirilla do not grow in culture media. 

Treatment. — The medical treatment is the same as for tonsillitis. 
If there is an adenitis, a cold compress (p. 290) should be applied. 



286 THE PRACTICE OF PEDIATRICS 

Locally, tr. iodine or peroxide of hydrogen applied twice daily to the 
ulcer appears to shorten the duration of the disease. 

SEPTIC SORE THROAT (MILK BORNE)* 

Epidemic sore throat due to an infection conveyed by milk has 
been of frequent occurrence in England for several years past. 

Since the Boston epidemic in 1911, visitations of the disease have 
been reported from various sections of this country. Doubtless out- 
breaks had previously occurred but had not been recognized as an en- 
tity. In a recent epidemic of 40 cases in which the author saw several 
patients there was a mortality of 15 per cent. 

Age. — All ages are susceptible, the greatest number of cases occur 
among the young, as would be expected. 

Etiology. — In the Boston epidemic of 1911 it was first conclusively 
demonstrated in this country that septic sore throat is a distinct 
clinical entity due to the streptococcus conveyed in a polluted milk 
supply. During this time, and at subsequent outbreaks, an examina- 
tion of the milk source led to the discovery of an epidemic of mastitis 
existing among the cows supplying the involved community, pus 
cells being found on several occasions in the milk. That the dairyman 
acting as a human carrier is also a factor in infecting the milk has been 
proven by the existence of a number of cases of sore throat among 
dairy employees, one of whom (in an epidemic) showed an abundant 
growth of almost pure streptococci. 

Pathology. — A general redness may be diffused over the pharynx, 
tonsils and soft palate simulating a scarlet fever throat or small 
isolated patches of exudation in the tonsillar crypts may make it re- 
semble an acute follicular tonsillitis. Later an extensive pseudomem- 
branous exudate may strongly suggest diphtheria. Both tonsils may 
be involved simultaneously, but more frequently one is infected before 
the other. The cervical lymph-nodes are always involved to some 
extent and occasionally very much swollen, terminating in suppura- 
tion in the severe cases. The extension of the inflammation to the 
deeper tissues about the neck often leads to a diffuse cellulitis of that 
region. 

Symptoms. — The onset of the septic sore throat is fairly uniform 
in its manifestations. It is usually sudden and attended by a chill in 
the great majority of cases. Nausea is also a frequent accompaniment 
of the early stages. The temperature rises rapidly to 103 or 105 and 
in the more toxic cases there is present general muscular pain and 
soreness and severe headache. A marked degree of prostration is pres- 
ent in the severe cases. The first period of the disease last from three 
to five days and a rapid recovery may follow in the mild cases or com- 
plications which may be numerous and dangerous may ensue and 
prolong the duration indefinitely. 

* Herman Biggs, N. Y. Medical Record, 1915 presents a comprehensive con- 
tribution on Milk Borne Septic Sore Throat. 



ACUTE CATARRHAL LARYNGITIS (SPASMODIC CROUP) 287 

Complications. — Cervical adenitis with possible suppuration and 
otitis media are the most frequent secondary involvements in the 
young. Peritonsillar abscess, nephritis, polyarthritis, pneumonia and 
peritonitis are occasionally seen, especially in those more advanced in 
years. 

Prognosis. — The prognosis is better in children and young adults 
than in those who are more advanced in years, due to the fact that they 
enjoy a comparative freedom from the above-mentioned complica- 
tions. The mortalities in recent epidemics according to the literature 
have varied from 2 to 5 per cent. 

Prophylaxis. — Pasteurization of all milk used for drinking purposes 
will prevent the establishment of the disease. Dairy employees should 
be under careful medical supervision. 

Treatment. — The treatment suggested for tonsillitis should be car- 
ried out here, together with throat irrigation (p. 278) and supportive 
measures. 

Autogenous vaccines should be prepared and used early in the 
disease. 

ACUTE CATARRHAL LARYNGITIS (SPASMODIC CROUP) 

In acute catarrhal laryngitis two factors are operative: the local 
infection causing a swelling and infiltration of the laryngeal mucous 
membrane, and the laryngeal spasm which is apparently excited by 
the local process. 

Etiology. — The disease may be primary or secondary to inflamma- 
tory conditions in the nasopharynx. Exposure to cold is a prediposing 
cause. Rachitic children, if they develop the disease, are liable to 
have it in a severe form. They are no more predisposed, however, 
than normal children. Adenoids and enlarged tonsils are predisposing 
causes. 

Illustrative Case. — A case which demonstrates the possible effects of sudden cold 
occurred at the New York Infant Asylum during my internship in that institution. 
A delicate baby, six months of age, was exposed for a few minutes on a very cold, 
windy, December day, with no head covering and simple ward clothing. Within 
an hour a croupy cough had developed, and in three hours intubation was necessary. 

Pathology. — Early in the attack the mucous membrane is swollen 
and free from secretion. In older children, in whom a laryngoscopic 
examination is possible, the mucous membrane is seen to be intensely 
congested and dry. When resolution begins, the parts appear glisten- 
ing and edematous. The lesion itself, however, is never sufficient to 
produce the obstruction to inspiration peculiar to these cases, as ^he 
mucosa is probably alone involved. 

Symptoms. — The onset may be sudden or gradual. Cases of 
gradual onset usually follow an acute inflammatory condition of the 
nasopharynx, the fauces and larynx becoming successively involved 
over a period of perhaps two or three days before the laryngitis is 
well marked. The temperature at the onset is usually not high. 
One of the early symptoms indicating laryngeal involvement is a hard, 



288 THE PRACTICE OF PEDIATRICS 

dry cough, croupy and ''barking" in character. The croupy cough 
increases in severity toward evening, and is often associated with 
urgent respiratory obstruction. 

In a typical case with sudden onset the following are the more fre- 
quent symptoms: the child retires at the usual hour in apparently 
good health ; a few hours later he wakes with the characteristic cough, 
active laryngeal spasm, cyanosis and labored efforts at inspiration in- 
volving dilatation of the alse nasi, suprasternal and infrasternal reces- 
sion, profuse perspiration, and rapid pulse. The expression is anxious, 
and the child cries in fear. The temperature is variable, but usually 
elevated. Expiration is usually unimpeded. Under right treatment 
the symptoms of spasm subside and do not recur on the following 
night. The cough which persists for a few days, subsides under proper 
treatment. In some of the cases, however, the course is not so favor- 
able ; the cough continues, becoming stridulous, every inspiration being 
accompanied by a loud, crowing sound, and in extreme instances the 
laryngeal obstruction due to the swelling and .laryngeal spasm, is so 
severe as to require intubation. In my experience, however, this is 
very rare, as I have had to intubate but one child with catarrhal, 
non-membranous croup — the infant already referred to. 

Differential Diagnosis. — Acute laryngitis may be confused with 
diphtheric or membranous laryngitis. (For differentiation, see p. 
631.) 

Laryngismus stridulus may be mistaken for catarrhal laryngitis. 
Differentiation is easy, when one remembers that in uncomplicated 
laryngismus stridulus there is no cough, and that the laryngeal spasm 
is usually associated with excitement, fright, or some other nervous 
influence. Furthermore, laryngismus stridulus does not occur as a 
definite acute illness; the laryngeal spasm, mild or severe, occurs, as a 
rule, several times a day over a period of weeks or months. The con- 
tinuous obstruction, always associated with inflammatory conditions 
of acute catarrhal laryngitis, is, moreover, absent in laryngismus. 

Retropharyngeal adenitis or abscess may be confused with catarrhal 
laryngitis. Respiratory obstruction in acute laryngitis is apparent 
only during inspiration, and the cough and dyspnea are usually of 
sudden onset. Retropharyngeal adenitis and abscess are characterized 
by a persistency of the symptoms while the disease is active. Digital 
exploration of the pharynx makes the differentiation final. In con- 
genital stridor, the stridor is relieved by stress or excitement, the 
noisy breathing and other evidences of obstruction being worst when 
the child is quiet or asleep. 

Treatment. — In the treatment of catarrhal laryngitis in children 
two conditions must be kept in mind : First, the inflammatory infiltra- 
tion and dryness of the parts, producing the metallic cough and the 
stridulous breathing; second, the laryngeal spasm, which is purely a 
nervous manifestation, doubtless due to irritation of the terminal 
filaments of the recurrent laryngeal nerves. 

By no means every case of laryngitis in children develops into croup. 



ACUTE CATARRHAL LARYNGITIS (SPASMODIC CROUP) 289 

When croup is present, however, we know that its existence is due to 
the association of laryngeal spasm with congestion and inflammation. 
If we are to promote quick recoveries, we must not lose sight of the 
important nervous element. 

Expectorants. — For the simple coughs, without accompanying in- 
terference with respiration, treatment with expectorants and steam 
is of great service, regardless of the age of the child. This treatment 
should be preceded by the administration of a full dose — from 1 to 3 




Fig. 27. — Crib prepared for steam inhalation. 

teaspoonfuls — of castor oil. To a child under one year of age a tablet 
composed of tartar emetic, Jfoo grain, with powdered ipecac J^o 
grain, should be given every two hours — 8 doses in the twenty-four 
hours. If the tablets or powders are not available, 2 drops of syrup 
of ipecac may be given instead. To a child from one to two years of 
age a tablet or powder composed of }ioo grain of tartar emetic, }4o 
grain of powdered ipecac, and 3^^ grain of Dover's powder may be given 
at two-hour intervals — 8 doses in twenty-four hours. After the first 
19 



290 THE PRACTICE OF PEDIATRICS 

day the treatment should be resumed early in the morning, so that by 
evening, when the cough and spasm are most severe, the full influence 
of the drugs may be secured. From the third to the sixth year 
powder or tablet composed of tartar emetic, J^o grain, powdered 
ipecac, 3^o grain, and Dover's powder, 3^^ grain, should be given at 
two-hours intervals — 8 doses in twenty-four hours. At least 8 doses 
of one of the above prescriptions should be given daily in order to get 
the full benefit of the drugs employed. If the Dover's powder pro- 
duces constipation, this ingredient may be omitted or counteracted 
by a laxative. Ordinarily treatment need not be continued more 
than two or three days. In case the attack is mild, the Dover's 
powder should be omitted. 

Cold Compresses. — In the treatment of older children the ap- 
plication of a cold compress to the throat is a valuable local measure. 
A napkin or piece of old linen so folded that there are at least six 
thicknesses of the material, should be moistened with cold water at 
60°F., wrung thoroughly, and placed against the neck, under the jaw, 
so as to extend from ear to ear. Over this should be placed a piece 
of oiled silk or rubber tissue held in position by a strip of thin mus- 
lin or cheese-cloth, which should be brought together at the ends and 
fastened at the top of the head. The compress should be changed 
every thirty minutes. In the management of very young children 
this measure is rarely satisfactory, for the reason that it is difficult 
to force the child to allow the bandage to remain in place. The prac- 
tice of placing the compress around the neck, as is often done, is of 
no value, as the dressing does not even overlie the diseased parts. 

Steam Inhalations. — Steam inhalations are effective only when the 
patient is kept in an inclosed space. Steam diffused throughout the 
room is of little or no service. The easiest and most practical place for 
the child is in its crib, which should be covered with a sheet. An open 
umbrella may be substituted when a crib is not available. Under the 
umbrella, which rests upon the bed, lies the child, and covering all is a 
sheet pinned to the umbrella. If preferred, the open umbrella, draped 
as before, may be placed over the baby-carriage. Any means or 
apparatus is adequate which will furnish steam and conduct it to the 
inclosed space. The Holt croup kettle when obtainable is always to 
be used. The steaming may be continued for hours. The sheet 
should be removed occasionally for a few moments, in order to allow 
a change of air. Usually a child may be kept under the tent from 
twenty minutes to one-half hour without such a change. The tent 
is seldom so close as to prevent all ventilation. 

Calomel Fumigations. — A quicker and more effectual means than 
the treatment with steam is the use of calomel fumigations. The 
patient is placed under a tent prepared as above. Ten grains of 
calomel are placed in any tin receptacle, which rests or is held over the 
flame. The Ermold lamp, made especially for this purpose, is recom- 
mended, although the ordinary alcohol lamp used for warming milk 
answers every requirement. An ordinary kerosene lamp has served 



TRAUMATIC LARYNGITIS 291 

me well in a few instances, the calomel being placed in the cover of a 
tin can which was held by a pair of pincers over the top of the lamp 
chimney. Regardless of the method the fumigation must be con- 
stantly watched by some competent person, so as to avoid the possi- 
bility of igniting the bedclothes. When the fumes begin to fill the 
tent, the child will cough considerably. If the cough continues for 
more than a few minutes, a portion of the vapor should be permitted 
to escape. The calomel will be consumed in from five to ten minutes, 
depending upon the degree of heat used. After the tent is filled with 
the vapor, the child may inhale it for about one-half hour. The 
vapor produces free secretion from the mucous membrane of the parts, 
and local depletion, resulting in enlargement of the lumen of the larynx 
and consequent relief of the symptom. The fumigations may be re- 
peated after an interval of two or three hours. If a non-diphtheric 
case I have rarely had to repeat the inhalations more than two or 
three times. 

Antispasmodics. — In the cases of sudden onset, in which the 
spasmodic element is prominent at the commencement of the attack, as 
indicated by the high-pitched, crowing inspiration, and in some ex- 
treme cases by the struggle for breath, the cyanosis, the stridor, and 
the infrasternal recession, the above treatment will not avail. We 
must combine an expectorant with antispasmodic drugs. A full dose of 
syrup of ipecac — one to two teaspoonfuls, or sufficient to produce 
emesis — should be given at once. If vomiting does not result in 
twenty minutes, the ipecac should be repeated. After emesis has 
taken place, the antispasmodic remedies should be brought into use. 
Antipyrin and sodium bromid are especially effective at this stage. 
Antipyrin appears to have a direct sedative action on the nervous mech- 
anism of the larynx. To a child two years of age the following pre- 
scription may be given : 

I^ Antipyrini gr. j 

Sodii bromidi gr- ij 

Syrupi ipecacuanhse nKij-iij 

Aquae q. s. ad 5j 

M. Sig. — One such dose every two hours — eight doses in twenty-four 
hours. 

To a child from three to six years of age may be given : 

I^ Antipyrini gr. ij 

Sodii bromidi gr. iv 

Syrupi ipecacuanhse gtt. iij 

Syrupi rhei gtt. xv 

Aquae q. s. ad 33\ 

M. Sig. — One such dose every two hours — eight doses in twenty-four 
hours. 

TRAUMATIC LARYNGITIS 

Traumatic laryngitis, although a very rare condition in children, is 
occasionally observed. It may be caused by the inhalation of steam 
or irritating gases or the aspiration of carbolic or other strong acids. 

I once saw a fatal case due to the aspiration of pure carbolic acid 
by a child three years of age who was given a teaspoonful of the acid 



292 THE PRACTICE OF PEDIATRICS 

by a five-year-old sister. As soon as it passed the lips the child cried 
and coughed. None of the acid was swallowed, apparently, but 
sufficient was aspirated into the larynx to produce intense congestion and 
sufficient edema to require immediate operative measures. The parts 
sloughed extensively and the child died in two weeks from pneumonia 
resulting from sepsis. 

Treatment. — No case of corrosive injury to the mucous membrane, 
sufficient to produce congestion and edema with a resulting inspiratory 
obstruction which requires operative relief, should ever be intubated 
except as a temporary expedient, since the presence of a tube will in- 
variably cause extensive sloughing. If the case is urgent, tracheotomy 
is the only justifiable operation. In two cases due to irritating gases 
(sulphur dioxid in one case and steam inhalation in another) the treat- 
ment consisted in the use of cold applications to the neck by means of 
wet compresses at a temperature of 60°F. Both cases recovered. 

LARYNGEAL OBSTRUCTION 

Laryngeal obstruction may be either complete or partial, causing 
entire cessation of, or greatly impeded, respiration. As the calls upon 
the physician for aid in these cases are attended with great urgency, 
it is well to bear in mind the conditions which may give rise to, or di- 
rectly cause, laryngeal obstruction. These are referred to in detail 
under their respective headings. In order of frequency they occur as 
follows : 

1. Acute Catarrhal Laryngitis (Catarrhal Croup), p. 287. 

2. Laryngismus Stridulus, p. 487. 

3. Retropharyngeal Abscess, p. 275. 

4. Foreign Bodies in the Larynx (see below). 

5. Traumatic Laryngitis, p. 291. 

6. New-growths. 

7. Membranous Laryngitis (Laryngeal Diphtheria), p. 636. 
Acute catarrhal laryngitis, membranous laryngitis, laryngismus 

stridulus, and retropharyngeal abscess are by far the most frequent 
causes of laryngeal obstruction in children. In children, edema is a 
very infrequent cause of laryngeal obstruction. When present, it is 
a complication or sequel of other pathologic states; for example, it 
may result from an inflammation accompanying a low-placed retro- 
pharyngeal abscess, a traumatic laryngitis after the inhalation of irri- 
tating gases, or from the aspiration of corrosive fluids or powders. 
The part played by the thymus gland in causing laryngismus is not 
at all clear — the subject has been discussed on page 487. 

Illustrative Case. — A patient eighteen months of age, during convalescence 
from a mastoid operation, developed a cellulitis in the tissue about the wound. 
The inflammation involved the entire side of the face, the lips, and mucous mem- 
brane of the mouth, and eventually extended to the larynx, producing edema, with 
most urgent symptoms of laryngeal obstruction. 

FOREIGN BODIES IN THE LARYNX 

Foreign bodies are usually lodged in the larynx by an act of sudden 
inspiration attended by a quick forward movement of the head, as in 



ADENOIDS 293 

coughing or laughing with a foreign body in the mouth or between the 
teeth. The patient is immediately seized with a violent paroxysm of 
coughing and suffocation, the severity of which depends upon the size 
and shape of the foreign body. 

Treatment. — Inversion of the patient has been of no service what- 
ever in the cases seen by me. The first procedure is to introduce into 
the mouth the index-finger, with the hope that a portion of the mass may 
protrude sufficiently to make possible its removal. Should the attempt 
fail, a laryngeal forceps should be brought into use, its introduction 
being guided and guarded by the index-finger. When this is not 
successful, tracheotomy should be performed to relieve the child from 
immedite danger of suffocation, after which further surgical procedures 
may be considered. 

ADENOIDS 

The recognition of adenoid growths as a cause of nasal obstruction 
has been appreciated only during the past thirty years. The vege- 
tations were first described by Dr. Wilhelm Meyer, of Copenhagen, in 
1868. 

Pathologically, they exist as overgrowths of the lymphoid tissue 
normally present in the nasopharynx. When the lymphoid elements 
alone are increased, the growths are soft and spongy, but when, as is 
frequently the case, there is marked development of fibrous tissue, 
they are firm and resistant. Increase in the connective tissue is 
primarily a perivascular process. Ultimately atrophy of the lymphoid 
tissue occurs, resulting in contracture of the adenoid mass. This 
change has been commonly attributed only to late childhood and early 
adult life. Such changes, however, are not uncommon in the very 
young. The spontaneous abatement of symptoms which is so fre- 
quently observed in young adults is more probably due to increase in 
the capacity of the epipharynx than to actual diminution in the size of 
the obstructing mass. 

Etiology. — Adenoids are found in all classes of children. In propor- 
tion to the population, they are as frequent among the wealthy and WeU- 
to-do, as among the poorer classes. In fact, if the throats of all chil- 
dren were carefully examined with the finger, adenoid vegetations in the 
nasopharyngeal vault would be found in 95 per cent, of the cases. This, 
however, does not mean that 95 per cent, of children should have the 
adenoids removed, as in some instances the growth is very small and 
fairly innocent. 

The fact that adenoids are so generally prevalent among all classes 
and conditions of children points to a conimon causative agent, or 
group of agencies. I believe that the wide prevalence of the growths is 
due to the following conditions: 

First : There is a tendency to overgrowth of lymphoid tissue in all 
children. 

Second : The location of the normal lymphoid tissue in the pharyn- 
geal vault, subjects this tissue to the irritation of dust and sudden 



294 THE PRACTICE OF PEDIATRICS 

currents of cold air, resulting in the pathologic changes described. 

Third: The first and second conditions prepare the parts for the 
action of the third factor — bacteria. 

A curved probe tipped with sterilized cotton when passed into the 
adenoid tissue of any child, whether the amount of tissue is small or 
large, will afford a culture of the secretion, in which may be found the 
streptococcus, staphylococcus, pneumococcus, influenza bacillus, and 
many other pathogenic organisms. The local congestion caused by 
the presence of hordes of bacteria further increases the hypertrophy 
of the adenoid mass. 

Heredity is of no immediate consequence. If a new race of children 
could be born free from adenoid antecedents, they would just as surely 
develop the growths. 

Age. — If a child passes the fourth year without adenoids, he will 
probably not acquire them later. Children are born with adenoids. 
At what period in utero they develop is not known. I have seen them 
at birth in infants with cleft-palate. Adenoids were present, in quite 
considerable amount, in oile infant who was one month premature. 
Signs of the growths do not ordinarily develop before the end of the 
first year. The great majority of cases come under observation be- 
tween the eighteenth month and the fifth year. I have operated 
upon four children nine months of age, because in each instance the 
parents insisted that the child be given relief from a growth which 
completely blocked the nasopharyngeal vault. The extremes as 
regards age in cases upon which I have operated are six months and 
fifteen years. While we do not see many cases until the patients are 
two or three years of age or older, I am convinced that, in a large major- 
ity, the process begins during the first year. 

Sjrmptoms. — Some children have large, roomy nasopharyngeal 
va,ults, while in others, on account of the high palatal arch and the 
prominence of the bodies of the vertebrae, this space is very small. 
In the latter cases a very small amount of adenoid tissue causes marked 
obstruction. The character and amount of the growth likewise de- 
termine the degree of inspiratory impairment and the severity of the 
related symptoms. 

Mouth-breathing. — In all cases showing a considerable growth, 
and in others in which a moderate growth exists in a small vault, 
mouth-breathing occurs, because the natural respiratory tract is 
partially blocked. 

Rhinitis. — A more or less persistent rhinitis is also present, and this 
is intermittent — now better, now worse. It is usually worse during 
the winter; during the summer in some cases it may disappear, only 
to return with the first cold weather. In other cases, with con- 
siderable adenoid growth, the nasal discharge never ceases, but is apt 
to be worse during the winter and spring months. The child cannot 
blow the nose, the voice and speech are defective, and the voice has a 
nasal quality. Certain letter sounds, such as "m" and '^n" in the 
words ''spring" and ''bang" are pronounced with difficulty. Be- 



ADENOIDS 



295 



cause of the presence of the mechanical obstruction in the natural re- 
spiratory passage, the child breathes through the mouth, not only 
when awake, but when asleep, and consequently snores, and is noisy 
and restless, tossing about and assuming all sorts of awkward positions 
during sleep. 

Adenoid Face. — These children all have the characteristic adenoid 
face. The term, mouth-breathing, does not describe the condition ap- 
parent in a pronounced case in an older child. The masseters become 
so relaxed that a habitual drop jaw results. The nostrils are usually 
small; the nasolabial folds are deepened. 




Fig. 28. — Adenoid face. 

Adenoids Without Facial Deformity. — In a child with a roomy vault, 
adenoids in small or medium-sized masses may be present without pro- 
ducing facial deformity or obstructive symptoms. 

Apart from the characteristic appearance of the patients, two 
symptoms suggest adenoids: 

First: Persistent rhinitis, indicated by habitual nasal discharge, 
which is ascribed to a chronic cold. 

Second: Cough, habitual, mild, or severe. It may be paroxysmal. 
I have repeatedly known this symptom to be confused with whooping- 
cough. (See p. 616.) The cough is always worse when the patient is 
lying down. Many of these cases pass unrecognized, adenoids being 
unsuspected because of the absence of obstructive signs, while the cough 
is attributed to the stomach, dentition, worms, nervousness, etc. 



296 THE PRACTICE OF PEDIATRICS 

Diagnosis. — The open mouth (see Fig. 28), the snoring at night, 
the stupid expression, the disturbed articulation, the persistent nasal 
discharge, the deafness, the inability to blow the nose, the cough, and 
the chronicity of the symptoms all combine to make a picture afforded 
by no other condition. No special type of child is affected. We find 
adenoids not only in the delicate and ailing, but also in the strong and 
well. Among hundreds of cases, I have seen very few in which a part 
in the production of the growths could be attributed to lymphatism. 

Method of Examination. — In children, after the fifth or sixth year, 
satisfactory examination by means of mirrors and illumination is oc- 
casionally possible. Occasionally a rhinologist will state that he is 
able to make all necessary examinations in much younger children, by 
means of posterior rhinoscopy. I have never seen this demonstrated 
and do not expect to. 

Although such procedure is disagreeable to the patient, I prefer the 
finger examination in all cases. The child is securely held by an at- 
tendant, with the arms pinned to the sides. A mouth-gag or tongue- 
depressor is then placed between the teeth, at right angles to the jaw, 
and held in position by the left hand of the examiner, thus allowing 
the right finger to be free for the examination. 

Association with Enlarged Tonsils. — In the very young, adenoids 
usually exist independent of enlargement of the tonsils. The older the 
child, the more frequent in occurrence is fhe involvement of the tonsils. 
Enlarged or diseased tonsils without adenoids are found only with the 
greatest rarity. 

Treatment. — Treatment other than by operation is highly ridicu- 
lous. 

The Operation for Temporary Relief. — Early infancy is no contra- 
indication to operation, if the conditions are sufficiently urgent. For- 
tunately, the necessity for a radical operation in those under one year 
of age is comparatively rare. These little patients, however, may have 
obstructing growths sufficient to give rise to mouth-breathing and dif- 
ficulty in nursing, and also to a very annoying and persistent nasal dis- 
charge. At this age the adenoid tissue is usually very soft and friable. 
In several instances I have temporarily relieved such an infant by 
crushing the growth with the clean index-finger tip wrapped in a couple of 
layers of sterile gauze. The finger-nail should be cut very short and 
the whole hand thoroughly scrubbed and disinfected. The child 
should be wrapped and pinned in a large towel, with the arms confined 
to the sides, and then placed on the back on a bed or table. A clean 
towel for wiping away the blood should be placed under the head. The 
mother and nurse should be advised that slight bleeding is expected. 
When the child is in position, the physician may hold the mouth open 
with a spoon or tongue-depressor, and then pass the index-finger of the 
right hand backward into the vault and easily break up the soft, spongy 
growth which may be present. The adenoids are by no means re- 
moved by this method, but their continuity is destroyed and portions of 
the growth doubtless slough off, thus affording temporary relief. The 



HYPERTROPHIED AND PERMANENTLY DISEASED TONSILS 297 

child will be able to nurse without inconvenience, and the nasal 
discharge will stop. In six months or a year, however, the symptoms 
will return and the radical operation should then be deferred no longer. 
The combined operation for the removal of both tonsils and adenoids 
which is the usual practice, will later be described. (See p. 298.) 

HYPERTROPHIED AND PERMANENTLY DISEASED TONSILS 

Chronic enlargement of the tonsils is usually the result of repeated 
attacks of tonsillitis. Notwithstanding this fact, I have repeatedly 
SQen enlarged tonsils which had never been inflamed. A tonsil is 
considered abnormally large when it extends beyond the pillars of the 
fauces. Enlarged tonsils not only produce mouth-breathing, faulty 
articulation, and catarrh of the Eustachian tube, but are doubtless a 
factor in the etiology of adenoids. 

Without being enlarged, a tonsil may still exist as a menace to the 
owner. The very small tonsil which is badly diseased, and the small, 
deeply buried tonsil, largely covered by the pillars, are sources of great 
danger. In the crypts — whether the organ is large or small — are har- 
bored myriads of bacteria capable of producing repeated attacks of 
acute inflammation. The streptococcus, staphylococcus, colon bacillus, 
pneumococcus, the tubercle bacillus, and the Klebs-Lofller bacillus 
all abound. The crypts of diseased tonsils unquestionably may supply 
the infective agent in pericarditis, endocarditis, nephritis, anemia and 
the various toxemias classified under the broad term of rheumatism. 
Adenitis, both tuberculous and simple, is very rare in children who do 
not have foci of disease in their throats. 

The Necessity for Operative Interference in Cases of Diseased Ton- 
sils and Adenoids. — The simple indication to relieve mechanical ob- 
struction is by no means the sole criterion in advising operative measures. 
Diseased tonsils are responsible in no small degree for many of the com- 
plications attending other diseases. In influenza, diphtheria, scarlet 
fever, and measles the throat always shows active participation. A 
child free from adenoids and diseased tonsils presents greatly increased 
resistance to all these diseases; and complications in such children, par- 
ticularly as relates to the lymphatic glands and ears, are most unusual. 
During even a common cold, however, a mass of adenoids in the vault 
serves as a very efficient means of conveying infection to the middle ear. 
A small percentage of middle-ear cases develop mastoid disease, and 
in a still smaller percentage sinus thrombosis, with or without jugu- 
lar involvement. In advising parents, the physician should clearly 
portray the culture-field which the child may be carrying in the upper 
respiratory tract. 

Operation for Permanent Relief. — I regard this as an operation 
with which the general practitioner should familiarize himself, and 
for this reason a description of the operative procedure is included in 
this book. The operation is not performed alike by all. Some prefer 
the sitting position without an anesthetic; others employ anesthesia 



298 THE PRACTICE OF PEDIATRICS 

and raise the patient to a sitting position at the time of the operation. 
It is my opinion that an anesthetic should be used in every case unless 
contraindicated by some such condition as lymphatism or cardiac or 
kidney disease, which might make the anesthesia dangerous. In 
operations upon children over two years of age my preference is to give 
nitrous oxid gas to produce unconsciousness, and then to substitute 
ether. This procedure is far more agreeable to the patient than the 
use of ether from the beginning. Primary anesthesia is all that is re- 
quired. In dealing with the very young, for whom gas is not per- 
missible on account of producing cyanosis, ether alone may be used. 
Chloroform I have learned to regard with much distrust. A boy three 
years of age upon whom I was to operate for adenoids came so near 
dying under chloroform anesthesia that resuscitation was almost 
despaired of. With another child I had a similar experience. I have 
never witnessed any unpleasant effects from ether during these 
operations. 

If the operation is to be performed without an anesthetic, the up- 
right position is best. The child's arms should be bound to the side 
with a large towel and fastened with safety-pins. He should be held 
on the lap on the right side of an attendant, who, by crossing his legs, 
confines between them the legs of the patient. The attendant 's right 
arm encircles the child, while the left controls the head, which rests 
against the attendant 's right shoulder. A basin should be within reach, 
as the bleeding is sudden and profuse. 

The Radical Removal of the Tonsils and Adenoids. — Until fifteen 
years ago my method was to remove as much of the tonsil as pos- 
sible by firm pressure with the tonsillotome and counterpressure 
by an assistant, but without any attempt at dissection or complete 
removal of the tonsil. This resulted in the removal of perhaps two- 
thirds or seven-eighths of the tonsil, leaving the capsule and some ton- 
sillar tissue. The great majority of my cases so operated upon were 
benefited permanently. In others the benefit was very temporary, 
the tonsil soon assuming the former size, the new-growth showing 
connective-tissue changes and adhesions to the pillars, which made the 
condition worse than it was before the operation. Even in the cases 
in which a regrowth of the tonsil did not occur the same tendency to 
tonsillitis persisted, and the tonsil remained a portal of entry for 
bacteria. Furthermore, second and third operations have been nec- 
essary under this procedure. I have performed the second operation 
after various other operators, as well as in my own cases. 

Forty-eight hours before the operation 10 grains of calcium lactate 
is given three times daily, the last 10 grains being given after 8 ounces 
of chicken broth, on the morning of the operation. I am convinced 
that the calcium lactate lessens the amount of hemorrhage. 

The method of procedure is as follows, after the method of Dr. 
F. S. Mathews: Ether or gas-ether anesthesia is used. The anesthetic 
is given to the point of abolishment of the corneal reflexes. The child 
is gagged sufficiently to allow the entrance of the index-finger, which 



HYPERTROPHIED AND PERMANENTLY DISEASED TONSILS 299 

must have free play, our object being to perform such a tonsillectomy 
as to strip the tonsil from its bed. For the right tonsil I pass my 
right index-finger into the mouth, and with moderate pressure and 
finger-point dissection, pass the finger into the superior fossa at the 
junction of the anterior and posterior pillar. I thus enter the finger 
above the tonsil, work down behind the capsule, pull the tonsil down- 
ward, and with the pressure exerted first anteriorly and then pos- 
teriorly, separate the structure from its attachments until it hangs 
by a pedicle formed by the mucosa and blood-vessels. Over this as 
small a tonsillotome as will engage the tonsil is slipped. The anes- 
thetist makes firm pressure from without, and the operator with firm 
pressure on the tonsillotome within cuts the pedicle. No tonsil tissue 
is cut. Without the interference of firm connective tissue, the blood- 
vessels in the pedicle readily contract. 

Mathews places the gag on the side opposite the immediate site of 
operation. I do not find this necessary except in very young children 
or those with small mouths. 





Fig. 29 




Figs. 29 and 30. — Adenoid curets. 

For the removal of the left tonsil a similar procedure is carried out, 
excepting that the left finger is used. I have had but little diflSculty 
in removing the entire tonsil by this method. 

The removal of the adenoids is very simple and requires but a few 
seconds. I use a modified Gottstein curet, which is built at an angle 
of about 45 degrees. (See Figs. 29 and 30). This allows greater play 
of the cutting blade in the vault. This curet is very sharp. Two or 
three sweeps suffice to remove all the adenoid tissue, hard and soft. 

When the patient is removed from the table, he has recovered suf- 
ficiently from the anesthesia to cry vigorously. He is given nothing 
but broths and gruels for the day. Six to eight hours after the 
operation an enema is given. The following da}^ he sits up in bed 
and plays. The next day he is up and about, and on the succeeding 
day, out-of-doors. Neither ice cream nor milk is given on the day of 
the operation. I have experienced no little trouble with children who 
have been given milk or ice cream within a few hours after the opera- 
tion. The indigestion and high temperature which are very apt to 
result alarm the family, who are inclined to attribute the manifestations 
to infection or something else of a very dangerous nature. 

It is claimed by the opponents of this finger method that complica- 



300 THE PRACTICE OF PEDIATRICS 

tions follow the operation, and that end results occur which are dis- 
tinctly harmful. I have had one case of postoperative adenitis which 
responded promptly to local treatment with cold applications. The 
child had a temperature of 102°F. to 104°F for three days. I have also 
had one case in which adhesions were formed by the pillars growing 
together. I have had no excessive hemorrhage at the time and no 
postoperative hemorrhage. This, I believe, is due to the fact, as men- 
tioned before, that the tonsil tissue is not cut and the vessels in the 
pedicle readily contract. 

Rarely have I found it necessary to use any other instrument than 
the finger. In three or four instances a pillar separator and blunt 
curved scissors have been necessary. The only instruments actually 
required have been the gag, the tonsillotome, and an adenoid curet. 

Conclusions. — The finger-enucleation method has the following 
advantages : 

Rapidity. — The child is kept under the anesthetic but a very short 
time. 

Completeness. — The entire tonsil is removed with little or no cutting. 

Absence of hemorrhage, for reasons already given. 

Short convalesence. 

Adhesions. — From six weeks to three months after the operation 
the nasopharyngeal vault should be e^camined for adhesions. The 
adhesions are usually attached anteriorly to the posterior surface of 
the inferior turbinates, oftentimes extending in a fan-shaped form 
to the posterior and lateral wall. My attention was first directed to 
the presence of these adhesions by mothers who brought their children 
for treatment stating that the adenoids had been removed and that 
the child was relieved for a few months, after which the obstruction 
became as marked as before. The operator was naturally blamed for 
not completely removing the adenoid tissue. 

Examination of the vaults in these cases disclosed the adhesions. 
These are usually readily removed with the finger. I have seen three 
cases, however, in which, on account of the firmness of the adhesions, 
this could not be done. One patient was recently operated upon by a 
New York laryngologist for relief of the condition. Besides limiting 
the normal breathing space these adhesions may cause a very teasing 
and troublesome cough. 

Illustrative Case. — A girl of nine years came to me because of a persistent cough, 
which had continued during the winter and which could not be relieved. She had 
been operated upon for adenoids four years before. I found fairly firm adhesions, 
which I reduced with the finger. The cough stopped at once. The mother then 
brought to me two other children who had shown unsatisfactory results from 
operations, both showing adhesions. 

By. many operators the existence of these adhesions is denied. I 
have found them after operations performed by men who said they 
did not know of them. Every physician will find them in many of his 
own patients if he will introduce his finger into the vault and search. 

Benefits of the Operation for Removal of the Tonsils and Ade- 
noids. — The usual advantages claimed, those relating to mouth-breath- 



POLLINOSIS, POLLEN DISEASE, HAY FEVER 301 

ing, facial deformities, etc., are sufficiently well known to be Omitted. 
I will call attention, however, to certain benefits that are perhaps not 
generally appreciated. 

In Delicate Children. — In my office work I have occasion to treat 
every year a large number of children who come because of defective 
growth, who are suffering from secondary anemia, or who are otherwise 
delicate. I have observed remarkable improvement in these children 
following the removal of diseased tonsils and adenoids. 

The Acute Injections. — In grippe, scarlet fever, measles, diphtheria 
and other acute infections, a considerable source of danger lies in the 
associated pyogenic infections of the throat and nasopharynx, involving 
secondarily the ears and the adjacent structures, the glands, and 
through the blood stream to the kidneys and the heart. The presence 
of diseased tonsils and adenoids supplies an ideal culture field for 
pyogenic bacteria and greatly enhances the child's chances for 
dangerous complications. For example, it is rare to find an otitis 
media in the absence of adenoids. 

Adenitis. — Adenitis, in any common form, is a very unusual occur- 
rence in a child who has had the adenoids and tonsils properly 
removed. 

Notwithstanding the large number of cases operated upon, I have 
yet to hear a regret expressed by the parents because the operation was 
performed. I have had occasion repeatedly to regret that a complete 
enucleation was not performed in my earlier cases. 

POLLINOSIS, POLLEN DISEASE, HAY FEVER 

Hay fever in children is by no means a rare disease. My youngest 
patient was three years of age. The disease is due to the influence of 
plant pollen on the mucous membrane of the nose and throat and 
represents a pollen protein anaphylaxis. A hay fever subject may be 
sensitized to one or half a dozen pollens. Individuals who react 
to horse serum or the odor of the horse or cat are very liable to be 
found sensitized to one or more plant pollens. 

The pollens of golden rod and rag weed are perhaps the pollens 
most frequently causing hay fever. Heredity appears to play an im- 
portant part in the etiology. Oppenheimer and Gottlieb* report that 
in 90 per cent, of their cases members of the family of the patients 
suffered with ailments showing manifestations of anaphylaxis. 

Diagnosis. — The disease may manifest itself any time during 
the period of the flowering of plants. The first sign is usually that of 
profuse lacrimation with itching and burning of the eyes. Sneezing 
and a profuse watery nasal discharge are rarely absent. In many 
cases asthmatic seizures develop. 

The seizures continue in a given case while the individual is sub- 
jected to the action of the pollen to which he is sensitized. As men- 
tioned above many hay fever subjects are sensitized to various pollens 
* Medical Record, March 18, 1916. 



302 THE PRACTICE OF PEDIATRICS 

and the disease may continue during the entire flowering period of plants 
from May until October. 

The Scratch Skin Test. — Individuals who are sensitized to a 
pollen will show a cutaneous reaction to the pollen protein. 

Technique of the Test.^ — The test is identical with that employed 
for testing for sensitization to horse serum, lactalbumen, or egg white. 

A small scratch is made on the skin, not sufficient to produce 
bleeding. Into this abrasion is rubbed the pollen of the plant to be 
tested. A similar scratch is made for control. If the individual is 
sensitized to the pollen used an area of redness and infiltration will 
appear at the site of the abrasion. 

This constitutes the reaction which will vary in degree from a 
distinct definable redness, Positive +, to the development of an ur- 
ticarial wheal, Postive + + + + , the varying degrees of reactions being 
indicated by the sign + . 

In the absence of reaction the test is recorded as negative. 

Cook and Vanderveer mention 25 plants which they have personally 
proven had caused hay fever. 

Treatment. — Those who desire to treat hay fever in the use of 
pollen preparations are advised to consult the publications of Cook 
and Vanderveer* and of Oppenheim and Gottlieb, t 

The Lungs 
examination of lungs 

Four methods are commonly employed in lung examination: 
(1) Inspection. (2) Palpation. (3) Percussion. (4) Auscultation. 

Inspection. — Inspection of infants and young children is of value 
in determining the existence and nature of any deformity, as well as the 
rapidity and character of the respiration. The frequency of respiration 
varies considerably in children. The younger the child, the more rapid 
the respiration. The variations are about as follows: 

Under one year of age 30 to 40 

One to three years of age 24 to 30 

Three to ten years of age 20 to 24 

The most common deformity is the rachitic chest or so-called pigeon- 
breast. In association with the rachitic chest, as one of the results of 
the rachitis, is found the funnel chest, which is characterized by marked 
depression of the sternum. 

The Depressed or Contracted Chest. — This condition is a result of 
pneumonia with pleuritic exudation and subsequent adhesions between 
the lung and the chest- wall. Dilatation of the lung is interfered with ; 
the balance between the intrathoracic and extrathoracic air pressure 
is not maintained, and deformity is the outcome. Inspiration is marked 
by a lack of motion on the part of the diseased side as compared with 
the normal side. 

* Journal Immunology, vol. i, no. iii. 
t N. Y. Medical Journal, no. vi, 101. 



EXAMINATION OF LUNGS 303 

The Distended Chest. — When there is effusion into the pleural 
cavity, and, rarely, when there is pneumothorax, one side of the chest 
may be much larger than the other. In thin subjects the marking of 
the ribs is much less pronounced than normal, the sunken interspace 
being obliterated by the pressure from within. In the distended 
chest also there will be observed a marked absence of respiratory move- 
ment. I have seen a great many cases, however, of pleuritic effusion 
in which such bulging was not present. 

Asthmatic or Fixed Chest.- — Chests of this type are quite common 
in children and are so characteristic that by watching the respiration 
one may readily make a correct diagnosis of the existing condition. 
In children normal breathing is of the costal type; that is, there is an 
outward movement of the ribs in inspiration and a downward and 
inward movement of the ribs in expiration. In the emphysematous 
and those undergoing asthmatic seizures, both sides of the chest be- 
come inactive and the respiration is largely diaphragmatic. 

Defective Expansion. — In pneumonia and in pleurisy there is de- 
layed and incomplete expansion of the diseased side. In pneumonia, 
also, there is unusual rapidity of respiration; and in acute pleurisy, 
characteristic, guarded, interrupted inspiration. In atelectasis the 
inspiration is very feeble and little or no expansion. In empyema 
and pneumothorax there is little or no expansion over the affected 
area. 

Palpation. — Palpation of infants and young children is of little 
value. Fremitus serves only to corroborate what may be learned by 
percussion and auscultation, and is not to be relied upon. The absence 
of fremitus in a thin or average built child usually means the presence 
of fluid in the pleural cavity, but, in a child with a thick layer of 
adipose, the sign is of little or no value. The presence of marked 
fremitus may mean consolidation of the lung. The absence of fremitus 
is no guarantee that there is no consolidation. 

Percussion. — The value of percussion depends upon the normal 
resonance of the chest when tapped with the finger or other instrument. 
What is known as normal resonance is the sound produced by percussion 
over an air-filled lung. The usefulness of percussion in physical diag- 
nosis depends upon the nature or quality of the note and the sense of 
resistance imparted by the chest to the percussed finger. When pos- 
sible, percussion should be practised with the patient in a standing or 
sitting posture. The child should be quiet, if possible, as crying not 
only disturbs the listener, but changes the quality of the note as a result 
of the air taken into the chest and the tension on the chest muscles. 
Light percussion with the finger is preferred to that obtained by plexi- 
meter. The chief value of percussion in pulmonary diagnosis is in de- 
termining presence of fluid in the chest. 

The terms employed for expressing the findings in a given case are 
normal resonance, tympanitic resonance, dulness, tympanitic dulness, 
and flatness. The possibilities of variations in the resonance within 
the normal are considerable. The position of the patient, the age of the 



304 THE PRACTICE OF PEDIATRICS 

patient, the condition of the patient, whether thin or fat, whether 
quiet or crying, are all factors which may cause the percussion-note to 
vary. The student should familiarize himself with the normal by 
percussing the chests of many normal children of different ages. 

Tympanitic resonance is obtained over a hollow body, as over the 
stomach, over a distended colon, or a pneumothorax. 

Dulness is characterized by short, high-pitched sounds, caused by a 
solid body or fluid within the chest cavity, which interferes with the 
production of the normal resonant note. 

Flatness is the extreme degree of dulness, and is best demonstrated 
by percussing a chest filled with fluid. An important feature in deter- 
mining dulness and flatness is the sense of resistance offered the percussed 
finger by the chest- wall. In the presence of contained fluid the elas- 
ticity and vibration of the chest-wall are greatly diminished and read- 
ily appreciated by the finger percussed. 

Auscultation. — Auscultation consists in examination of the lung by 
the ear placed directly against the chest, or assisted indirectly by a 
stethoscope (p. 309). The use of the stethoscope in infants and young 
children is almost a necessity. On account of the smallness of the chest 
and the comparatively large surface of the field covered by the ear during 
direct auscultation, a larger area of sound conduction is covered than 
is desirable for purposes of accurate diagnosis. The small stethoscope 
bell is best, for the reason that when applied to the chests of emaciated 
infants, it will fit the surface better than a large bell. If the bell does 
not accurately fit the chest, extraneous sounds render examination im- 
possible. For accurate work with infants the unaided ear — so-called 
immediate auscultation — is out of the question. With older children, 
after the third or fourth year, the ear alone may be employed if the phy- 
sician is unable to accustom himself to a stethoscope. The physician 
must accustom himself to correct auscultation with the child crying. 
This, of course, means forced breathing and a great deal of extraneous 
noise. To one who is accustomed to lung examination of young infants 
it matters little whether or not the child cries ; in fact, in many instances 
crying is of distinct advantage, because it brings out the respiratory 
quality of all portions of the lung. In older children forced breathing 
is necessary to transmit the sounds we require for diagnosis. 

In auscultation all the diagnostician's attention is required for the 
work in hand. Concentration of the mind is most necessary. For 
years I have taught students to close their eyes during auscultation, 
for the purpose of removing all visual objects. All sounds appear 
louder in the darkness or when the eyes are closed. The position of the 
examiner is important. He should sit erect or lean slightly forward, 
but never incline his body more than 45 degrees. When the examiner 
leans too far, the circulatory changes in his ears make his work un- 
satisfactory and uncertain. In auscultation it is the object of the 
student to familiarize himself with the sound produced in the lung 
and transmitted to the chest-wall in the act of normal and forced breath- 
ing. The sounds thus produced are known as those of vesicular 
breathing. 



EXAMINATION OF LUNGS 305 

Vesicular breathing has a range of variations within the normal. 
As in the matter of the study of percussion sounds, repeated examina- 
tions of the chest of normal children of various ages and conditions 
are absolutely required before the nature of normal breathing and its 
possible variations will be appreciated. Various terms have been used 
in a comparative sense to describe vesicular breathing, such as '' rust- 
ling," '^blowing," ''swishing," ''purring," etc.; these are all mislead- 
ing and useless because there is no other sound resembling the sound 
of vesicular breathing which deserves mention in comparison. Differ- 
ent investigators have attempted, by means of various devices, to 




Fig, 31. — Vesicular breath- Fig. 32. — Distant vesicular Fig. 33. — Exaggerated 
ing. breathing. vesicular breathing. 

produce the sounds resembhng the respiratory murmur in health and 
its changes in disease, without success. 

The respiratory cycle includes the taking of air into the chest — 
inspiration; and the forcing of the air out of the chest — expiration. 
The duration of inspiration in comparison to expiration is in the ratio 
of five to three. The inspiratory sound is not only longer, but harsher 
in quality than that of expiration. The respiratory characteristics 
are diagrammatically described by Cabot, in his excellent work on 




Fig. 34. — Bronchial breath- Fig. 35. — Distant bronchial Fig. 36. — Very loud 
ing of moderate intensity. breathing. bronchial breathing. 

physical diagnosis. Cabot's diagrams are here used, but modified to 
correspond to the respiratory peculiarities of children. 

Inspiration is represented by the upward stroke and expiration by 
the downward stroke. The length of the upstroke, as compared with 
that of the downstroke, corresponds to the length of inspiration as com- 
pared with that of expiration. The thickness of the upstroke as com- 
pared with that of the downstroke represents the intensity of inspira- 
tion as compared with that of expiration. The pitch of inspiration as 
compared with that of expiration is represented by the sharpness of the 
angle which the upstroke makes with the perpendicular. 

In the foregoing, an attempt has been made to describe the various 
20" 



306 THE PRACTICE OF PEDIATRICS 

phases of normal respiration. That the two sides of the chest may show 
considerable variation within the normal, due to changes in the posi- 
tion of the body, the age of the patient, and whether he is at rest or 
active, as in crying, must be appreciated and learned only by repeated 
studies of the normal. Only when the student has so practised upon 
and studied the normal chest is he ready to take up the study of the 
signs of disease. 

Exaggerated breathing occurs when a sound lung or portion of a 
sound lung is called upon to do an extra amount of work. This type 
of breathing is simply compensatory, and occurs when a considerable 
portion of lung structure is incapacitated by consolidation, as in pneu- 
monia, or by pressure, as in the event of effusion into the pleural sac. 

Diminished or weakened breathing exists when both inspiration and 
expiration are feebler than the normal. 

Diminished breathing may be due to fluid in the pleural cavity, to 
pleuritic plastic exudation covering the lung like a blanket, to partial 
infiltration of the air-cells, to pneumothorax, to bronchitis, because the 
air is impeded in its passage to the air-cells, and to acute pleurisy which 
gives rise to much pain and causes a much shorter excursion of the chest- 
walls than normal. In all these conditions inspiration is less deep than 
normal, and diminished respiratory sounds are the result. In laryngeal 
spasm and in diphtheric laryngitis the respiratory murmur may like- 
wise be greatly weakened because of the failure of sufficient air to pass 
the obstruction. 

Bronchial breathing is symbolically represented and described by 
Cabot as follows: 

The increased length of the downstroke corresponds to the increased 
duration of expiration, the greater thickness of both lines corresponds 
to the greater intensity of both sounds, expiratory and inspiratory, 
while the sharp pitch of the gable on both sides of the perpendicular 
corresponds to the high pitch of both sounds. Expiration, it will be 
noticed, slightly exceeds inspiration, both in intensity and in pitch, 
but considerably exceeds it in duration. As compared with those of 
vesicular breathing, almost all the relations are reversed. 

Bronchial breathing is found in conditions in which there is com- 
plete infiltration of the alveolar air-cells, leaving only the bronchi 
open to the inspired air. The vesicular element in the breathing is, 
therefore, wanting, and the sound produced by the passage of air 
through the tubes is alone conveyed to the ear; and the more readily 
because of the solidity which the consoh dated lung presents. Any 
condition, by causing consolidation of the lung, obliterating the air 
spaces, may produce bronchial breathing. Thus bronchial breathing 
of the most pronounced type may be found over a pleural sac filled with 
fluid. The lungs solidified by the pneumonia or compressed by fluid 
(carnified) give rise to bronchial breathing which is readily transmitted 
by the fluid under compression to the surface of the chest- wall. Bron- 
chial breathing heard all over the chest (front, back, axilla, and apex) 
almost without exception means that the pleural cavity is filled with 



EXAMINATION OF LUNGS 307 

fluid, A failing to recognize fluid under marked signs of general 
bronchial breathing is one of the most frequent errors made in chest 
diagnosis in children. 

Bronchovesicular Breathing. — I do not recognize broncho vesicular 
breathing as a distinct type, but one of the forms of weakened or defec- 
tive breathing. 

In emphysematous breathing the inspiration is short and somewhat 
feeble, but not otherwise remarkable. The expiration is long, feeble, 
and low pitched. 

Asthmatic breathing differs from emphysematous breathing, the 
latter being characterized by greater intensity of inspiration. In 
asthmatic breathing, however, both sounds are usually obscured to a 
great extent by the presence of piping and squeaking rales. 

Cavernous Breathing. — Cavernous or amphoric breathing will be 
found over a cavity or a large bronchiectasis. The respiratory sound 
has a peculiar hollow quality, both upon inspiration and upon expira- 
tion. A low note is produced which has been compared to the sound 
produced by blowing gently into a wide-mouthed bottle. 




Fig. 37. — Emphysematous breathing. Fig. 38. — Asthmatic breathing : s, s, s, 

squeaking (musical) rales. 

Rdles. — Upon auscultation of the lungs rales of different kinds will 
be heard. A rale is the sound produced by impeded air in its passage 
through a bronchus to the lung. This may be brought about through 
a spasm of the tube, through thickening of its mucous membrane, or 
the presence of pus, mucus, or water in the bronchial tube. Rales 
of various types will be produced, depending upon the nature of the 
lesion and the size of the tube affected. Thus when there is congestion 
with infiltration, there will be sonorous rales in the large tubes and 
sibilant rales in the smaller tubes. 

Sonorous rdles are low-pitched snoring sounds, roughened and grat- 
ing in character. Stridor in larj^ngitis is akin to the sonorous rales. 

Sibilant rdles are squeaking, hissing, and crackling in character. 
In the smaller tubes they indicate the same condition as is productive 
of the sonorous rales in the large tubes, with this difference, that the 
advent of bronchial spasm is a considerable factor in the production of 
sibilant rales. Sibilant rales are almost always present in asthma and 
in asthmatic bronchitis, and may indicate an early stage of bronchitis. 

Mucous or Moist Rdles. — Mucous or moist rales are large, medium, 
and small; and vary in size and number, depending upon the nature 
of the lesion. They are produced by the passage of air through 



308 



THE PRACTICE OF PEDIATRICS 



diseased bronchi containing exudation, and are present in all catarrhal 
conditions of the lung from whatever cause. In bronchitis and 
bronchopneumonia, if the examiner is sufficiently industrious, every 
variety of rale may at some time be heard. 

The Stethoscope. — The stethoscope (Fig. 39) is the best instrument 
for use with children. There are two requirements which every 
stethoscope should fulfil. The ear-pieces must fit the ear, and the 




Fig. 39. — Stethoscope. 

pressure of the spring should be sufficient to hold them in position 
without causing discomfort. Flexible rubber connecting tubes are 
preferred. They should be from 9 to 12 inches in length, thus allowing 
the operator to move the bell freely over the chest without following the 
instrument with his head. The long tubes are further better in that 
they permit the physician's head to remain at greater distance from the 
child, thus preventing fright in a timid patient. The chest-piece or 



EXAMINATION OF LUNGS 



309 



bell should be small, so as to fit snugly the chests of thin children. The 
diameter of the bell employed in my own work is ^}iQ inch. 

The Bowles stethoscope (Fig. 40) differs from the foregoing in the 
shape of the chest-piece, which consists of a flat, saucer-shaped piece 
of metal, the orifice of which is covered over by a thin metal diaphragm. 
The only advantage possessed by this device is that it enables the phy- 
sician to examine the child without the change of position and other 
manipulation necessary in using the instrument first described. For 





Fig. 40. — The Bowles stethoscope. 



this reason the Bowles stethoscope is useful with children desperately 
ill, for whom such manipulation is not a safe or desirable procedure. 
The flat chest-piece which is attached to a flexible tube can readily be 
slipped under the child, and the examination conducted with the least 
possible disturbance. This stethoscope, however, should not be used 
in routine examination, as it accentuates all the chest and heart-sounds, 
(which in children are sujficiently plain to be detected by the ordinary 
instrument), and gives an exaggerated impression of the intensity of a 
normal sound. In instances in which there is weakness of the respira- 
tory or cardiac sounds, this instrument may be of service. 



310 THE PRACTICE OF PEDIATRICS 



BRONCHITIS 



Acute bronchitis, an infection of the bronchial mucous membrane, 
occurs with great frequency in infants and young children. 

The majority of cases occur during the colder months of the year, 
when houses are overheated, and when sudden changes in the weather 
are frequent. The sudden advent of exposure lowers the child 's resist- 
ance, and the infecting agents which are always present are then given 
a favorable field for activity. 

Predisposing Causes. — The chief predisposing cause is absence of 
resistance to bacterial invasion — a condition peculiar to child life. 

Infants and children who are rachitic or who suffer from other forms 
of malnutrition are particularly susceptible. Chronic rhinitis, enlarged 
tonsils, and adenoids are predisposing factors of no small consequence. 

Bacteriology. — The usual bacteriologic agents are the pneumococcus, 
the influenza bacillus, the staphylococcus, and the streptococcus. 

Types. — Bronchitis may be divided clinically into three types: 
Primary, secondary, and chronic. 

Primary. — Asthmatic (p. 316) .• — Simple. — In simple primary bron- 
chitis there may have been an exposure to cold or wet, although this is 
not at all necessary. The disease is more apt to follow exposure to 
another individual who has a so-called " cold," and who is, temporarily, 
at least, a germ carrier. 

Secondary. — This type is most often found associated with measles, 
whooping-cough, and grip, or following an acute catarrhal infection of 
the upper respiratory tract. 

Chronic. — ^Chronic bronchitis is somewhat rare in the young. It 
occurs most frequently in conjunction with asthma, or in slow con- 
valescence after bronchopneumonia, and is always present in chronic 
pulmonary tuberculosis. 

Pathology. — In simple bronchitis the lesion is very slight. The 
mucous membrane may show congestion and slight round-cell infiltra- 
tion, and there may be elevation or loss of superficial epithelium in 
small areas where the infection is most severe. 

Symptoms. — The onset of acute bronchitis is usually sudden. 
There is cough, which may be extremely troublesome, interfering with 
sleep, and, in the case of young infants, rendering the nursing and 
bottle feeding difficult. The respirations are rarely accelerated above 
30 per minute unless there is an associated bronchial spasm. (See p. 
316.) There may be moderate prostration; in mild cases there is none. 
In severe cases the appetite is interfered with. The child is rather 
peevish and shows general discomfort. 

Fever. — The usual range of the fever in uncomplicated bronchitis 
is from 100° to 102°F. When the temperature remains above 102°F., 
or makes frequent excursions above this point, I have always found 
a complication of some kind — something other than bronchitis — to 
account for the temperature. Frequent sources are some intestinal 
disorder, a developing otitis, or a beginning bronchopneumonia. If 



BRONCHITIS 311 

the temperature ranges above 102°F. and the respiration is 40 or more, 
we may be almost certain of a developing pneumonia. 

Physical Signs. — Auscultation of the chest early in an attack will 
reveal a harsh, roughened respiratory murmur, fairly evenly distrib- 
uted all over the lungs. Sonorous, sibilant, and mucous rales become 
audible in from twelve to thirty-six hours. 

Percussion.- — There is no change in the percussion-notes except in 
the cases of asthmatic bronchitis (p. 316), which show hyperresonance 
or tympanitic dulness. 

Palpation is here of no aid. 

Duration. — -The duration of an attack of bronchitis depends to some 
extent upon the child's recuperative powers, but to a much greater 
degree upon the method of treatment. A primary case properly man- 
aged should be well in five days. Many cases are not treated at aU 
by a physician. It is these cases of neglected bronchitis which furnish 
a great majority of our cases of bronchopneumonia, a disease which 
contributes largely to the mortality of children under five years of age. 

Diagnosis. — Signs of consolidation in the lung are not necessary 
for the diagnosis of pneumonia. Cases very often reported as those 
of capillary bronchitis, in which there is rapid breathing,- — 40 to 60 a 
minute, — high temperature, — 103° to 105°F., — and marked prostra- 
tion, show at autopsy the pneumonic elements which gave during life 
no other signs in the chest than a diminished respiratory murmur and 
many fine mucous rales. Catarrh of the bronchial tubes, manifested 
by many rales of different types, is the chief diagnostic feature of the 
disease. 

Secondary bronchitis differs from the acute primary form only in 
the mode of onset. In the secondary type the onset is gradual — three 
or more days usually being required before the disease is well advanced. 

In chronic bronchitis the physical signs consist of various types of 
mucous rales in the bronchi. The medium-sized bronchi are, as a rule, 
the chief seat of this catarrhal process. 

Cough is the most active symptom, and is worse at night. Fever, 
if present, is due to the associated disease, as chronic bronchitis in a 
child is rarely an independent illness. 

Treatment.- — The management of the primary and secondary cases 
is, in the main, the same, varying, of course, to meet individual condi- 
tions or symptoms. 

Before indicating what should be done in a case of bronchitis it may 
be as important, by way of emphasis, to advise what not to do. Do 
not seal the room up tight by keeping all the windows closed. Do not 
use an oil-silk jacket lined with wadding or any other material- Do 
not allow the child to be wrapped in blankets and shawls and held 
against a warm adult body. Do not give the child large doses of so- 
called '^ expectorants " — a teaspoonful of a heavy syrup. The tempera- 
ture of the room should be kept as near 68°F. as possible. . There 
should always be direct communication with the open air. A window 
lowered an inch or two from the top, or the window-board described 



312 THE PRACTICE OF PEDIATRICS 

on p. 138, is a safe means of assisting in ventilation. The child should 
be kept in his crib and wear the night-clothing to which he was 
accustomed in health. Many children with bronchitis do not feel 
particularly ill and rebel against the enforced inactivity. A patient 
who can not be kept under the covers may wear a pinning-blanket 
or a bath-robe while sitting up in bed, but should not be allowed 
to sleep in either. 

The Diet. — If there is little or no fever, the diet need be reduced 
but little. If there is fever, 100° to 101. 5°F., with restlessness and 
irritability, the food should be reduced in strength, the same amount 
of fluid being allowed as in health, the reduction being made by giving 
plain boiled water frequently to drink between the feedings. The 
diet of a nursing baby can best be reduced by giving a drink of water 
before each nursing, and shortening the time allowed for nursing from 
one-third to one-half. We will thus avoid digestive disturbances, 
which often act as a very serious complication of the existing disorder. 
Older children, receiving a mixed diet, may be given toast, cocoa, milk, 
broths, gruels, and fruit-juices. 

Steam Inhalations. — Properly administered medicated steam in- 
halations are of greater service in bronchitis, particularly in young 
infants, than any other form of treatment which we possess. The 
steaming is best administered with the child placed in the crib, 
which is covered and draped with sheets. A croup kettle with 
alcohol lamp attachment is the most convenient means for gener- 
ating steam. The nozzle of the croup kettle, which rests on a chair or 
stand, is carried under the tent at a safe distance from the child's hands 
and face. For inhalation, creosote has given better results than has 
any other drug. Ten drops are added to one quart of boiling water 
and the steaming is continued for thirty minutes. Ordinarily, in an 
urgent case, steaming for thirty minutes is given at two-and-a-half -hour 
intervals day and night until the child recovers. Older children, and 
those in whom the condition is not grave, need not receive the steam 
after the bedtime of mother or nurse. It is well to allow a change of 
air in the inclosed space at least three times during the steaming. 
This is done by raising the sheet for a moment or two and then replac- 
ing it. The side of the crib, if preferred, need not be draped. 

Counter irritation. — Counterirritation of the skin over the thorax is 
another very useful method of treatment in bronchitis. Full instruc- 
tions must be given the mother and nurse as to how the counterirri- 
tant is to be applied, or the application will be very indifferently made. 
In my hands the mustard plaster has been the most convenient means 
of counterirritation, and has given the best results. It is well to begin 
with a strength of one part of mustard and two parts of flour. Two 
or three apphcations of this strength may be made. Later, when the 
skin becomes sensitive, the plaster is to be made weaker by the addition 
of more flour, one part of mustard to five or six of flour. In order to 
be effective the plaster should remain in contact with the skin from 
five to fifteen minutes, until a diffuse blush appears. The plaster is 



BRONCHITIS 313 

prepared as follows: Mix the mustard and the flour, using hot water 
until a paste of medium thickness is formed. This is to be spread on 
cheese-cloth, old linen, or thin white muslin, to a thickness of about 
3^ inch. Over this one thickness of cheese-cloth should be placed. 
The size of the plaster depends upon the age of the child and the area 
of lung involved. In a case of general bronchitis the entire thorax, 
front and back, should be covered. It is easier to make two plasters 
which meet under the arms than to make one to encircle the thorax, 
as is sometimes done. A circle is cut out for the arms at the upper 
corners. The plasters are sufficiently large to meet at the sides, as 
mentioned above, when they may be pinned together. When all is 
completed, the application really amounts to a mustard jacket. The 
plaster may be applied from two to four times daily, depending upon 
the urgency of the case. Gounterirritation thus made is of great ser- 
vice early in the attack — during the stage of acute congestion. I 
question whether plasters are of much use after two or three days have 
elapsed. After removal of the plaster an application of vaselin is 
grateful to the patient. 

Mustard Baths. — A mustard bath, }^ ounce of mustard to 6 gallons 
of water, at a temperature of 110°F., is of considerable service in the 
very acute cases in young children, with extensive involvement of the 
fine tubes, usually known as '' capillary bronchitis," in which there is 
a great deal of bronchial spasm. This condition is very apt to develop 
into bronchopneumonia, even if the pneumonia does not exist from 
the beginning, which is probably the case. There is considerable 
shock; the hands and feet are often cold; the respiration is rapid, and 
the child is considerably prostrated. The bath may be repeated with 
advantage at intervals of from six to eight hours. The child is to 
remain in the bath from one to three minutes. While in the bath the 
trunk and extremities should be briskly rubbed with the bare hand. 

Drugs. — The value of drugs in the management of this disease has 
been considerably overestimated, and they are mentioned last because 
they are the least important of the remedial agents referred to. 

During the first stage of bronchitis, that of engorgement, indicated 
by a short, dry cough, and rough, sonorous breathing, small doses of 
castor oil and syrup of ipecac constitute our best medication. From 
the first to the third year, two to three drops of castor oil and two to 
three drops of syrup of ipecac may be given every two hours ; after the 
third year, three drops of syrup of ipecac and five drops of castor oil 
every two hours. At least eight doses should be given in twenty-four 
hours. Ordinarily, after twenty-four hours, auscultation will reveal 
a freer secretion in the bronchi, the fever will diminish, and the child's 
cough will become loose and less severe. The benefits from the oil 
and ipecac will be obtained in from forty-two to seventy-two hours, 
after which this medication should be discontinued. 

If the cough and the chest sounds tell us that the bronchi are not 
yet clear, a combination of tartar emetic, powdered ipecac, and am- 
monium chlorid may be used. To a child under six months of age a 



314 THE PRACTICE OF PEDIATRICS 

powder or tablet containing 3^f 50 grain of tartar emetic, 3^go grain of 
powdered ipecac, and 3^ grain of ammonium chlorid should be given 
at two-hour intervals, eight doses in twenty-four hours; from six 
months to one year, tartar emetic, Koo grain; powdered ipecac, 3^o 
grain; ammonium chlorid, 3^ grain, at two-hour intervals, eight doses 
in twenty-four hours. If the cough is very annoying and severe, re- 
quiring a sedative, 3^^ grain of Dover's powder may be added to each 
dose for children under six months, and J^ grain for children over six 
months of age. From one to three years of age, tartar emetic, 3^f 00 
grain; powdered ipecac, J^o grain; ammonium chlorid, 3^^ grain, may 
be given at two-hour intervals, eight doses in twenty-four hours, 3^^ 
grain of Dover's powder to be added to each dose if the character of 
the cough demands it. The tablet or powder, whichever is employed, 
should be given in two teaspoonfuls of thin gruel or plain water. 
After the third year J-^o grain of tartar emetic, ^io grain of pulverized 
ipecac, and 1 grain of ammonium chlorid may be given every two hours, 
eight doses in the twenty-four hours. The use of tablets or powders 
should be insisted upon, particularly in treating very young children. 
The large doses of ammonium salts and ipecac in heavy syrups are to 
be avoided because of their liability to produce stomach disturbance. 

The treatment of secondary bronchitis depends to a certain extent 
upon the disease with which it is associated, and the treatment should 
be modified accordingly. Counterirritation and medicated steam in- 
halations ordinarily can be used, as they interfere but little with other 
necessary treatment. 

Treatment of Chronic Cases. — In chronic bronchitis the removal of 
enlarged tonsils and adenoids, fresh air, and change to a dry climate, 
if possible, are our best means of treatment. In addition, general sup- 
portive treatment is to be advised. (See The Management of Delicate 
Children.) Creasote in small doses, 1 to 3 minims after meals, for a 
child from two to five years of age, has seemed to me to be of service 
with some of these children. My greatest success, however, with 
these cases has been achieved by ignoring the bronchitis temporarily 
and putting the child in the best hygienic surroundings. Outdoor life 
inland and a nutritious diet are far better than drugs. In many of 
these cases, under such a regime, the disease for which the child was 
brought for treatment has entirely disappeared without any specific 
medication whatever, showing that the bronchial catarrh was nothing 
more or less than a manifestation of greatly reduced vitality. 

Differential Diagnosis. — Chronic bronchitis may be differentiated 
from pulmonary tuberculosis by the temperature range, elevation of 
the temperature being absent in bronchitis. The examination of the 
sputum and the von Pirquet skin test are sufficient to establish a 
diagnosis. 

RECURRENT BRONCHITIS 

Recurrent bronchitis without the association of asthma and without 
fever or prostration is occasionally encountered. A typical case of 
this kind is as follows: 



RECURRENT BRONCHITIS 315 

IlliLstrative Case. — A plump, well-nourished, four-year-old girl had a history of 
attacks of bronchitis lasting from five to seven days at intervals of not longer than 
three weeks. The physical examination was negative. The attacks commenced 
when she was two years of age and had continued for two years. There never was 
a temperature of over 100°F. with the attacks, and the child was not physically ill. 
There had never been cyclic vomiting, tonsillitis, or rheumatism. The father was 
a sufferer from chronic rheumatism. The patient was given a diet suitable for her 
age (p. 108), meat being allowed every second day. The considerable quantity of 
sugar which she had been taking was greatly reduced, only enough being allowed to 
make the food palatable. She was given the following prescription: 

I^ Sodii salicylatis (wintergreen) gr. xxxvj 

Sodii bicarbonatis gr. Ixxij 

Ehx. simplicis 5v 

Aquse q. s. ad 5 ij 

M. Sig. — One teaspoonful twice daily after meals. 

The above prescription was given for five days, followed by an interval of five 
days' rest. This procedure was continued for five months, during which time 
there was no bronchitis. Later this medication was given ten days each month for 
one year, with entire relief of the trouble. Withholding sugar and fat from the diet 
was continued indefinitely. The patient has had no further inconvenience. 

When a child develops joint or bone diseases, the family can usu- 
ally recall an injury or fall of some sort to account for the trouble. 
So, also, in the event of bronchitis, an exposure, a change of clothing, 
or a change in the weather will usually be regarded as a cause of the 
attack. 

In the case above cited, and in many others, such factors evidently 
have had very little, if anything, to do with the bronchitis, for under 
the same climatic conditions the attacks cease when attention is given 
to the constitutional condition, and proper diet and medication are 
prescribed. The patients are usually of gouty or rheumatic ancestry. 

Treatment. — I have successfully treated a large number of these 
children. Sugar and fat cannot be taken by them. 

They should lead an active outdoor life when climatic conditions 
allow. There should always be communication between the sleeping- 
room and the outer air. All possible influencing factors, such as en- 
larged tonsils and adenoids, are to be removed. (This operation, 
however, is never sufficient in itself to prevent recurrences.) 

Diet. — Red meats, including beef, mutton, and lamb, should be 
given only every second or third day. Sugar is permissible only in 
sufficient amount to make the food palatable. If the case resists 
treatment, sugar is to be discontinued and saccharin substituted. 
Skimmed milk may be given as a drink, eight ounces being allowed 
both for breakfast and for supper. Green vegetables and cereals well 
cooked and suitable for the age may be given freely. 

There must be a free evacuation of the bowels daily. If there is a 
tendency to constipation, the management suggested on page 244 is 
to be brought into use. 

Medication. — These patients are not influenced by the usual treat- 
ment for bronchitis, so that expectorant drugs may be omitted. Large 
doses of bicarbonate of soda do more toward shortening the attacks 
than do any other forms of medication. To a child five years of age 
ten grains should be given at two-hour intervals. 

The interval treatment, with diet, must be relied upon to prevent 



316 THE PRACTICE OF PEDIATRICS 

a recurrence of the attacks. Salicylate of soda (wintergreen) is given 
for five days, in doses of from three to five grains, well diluted, after 
meals. The salicylate is then discontinued and the bicarbonate is 
given for ten days in the same dosage, when the salicylate is resumed. 
In this way, by alternating the two drugs or by giving aspirin when 
the salicylate disagrees, the treatment is continued for two or three 
months. As the case improves, an interval of rest from all medication 
is instituted. If it is more convenient, the salicylate and the bicar- 
bonate of soda may be given at the same time. 

Bathing. — The skin in these cases should be kept active, and once 
daily the child should be given a tub-bath in lukewarm water. After 
the bath a cool spray or spinal douche is used, the temperature of the 
water ranging from 50° to 70°F. An excessive degree of cold is not 
advisable; it should be sufficient, however, to insure good reaction 
after a brisk rubbing with a rough towel. 

ACUTE SPASMODIC BRONCHITIS (BRONCHIAL ASTHMA) 

Infants and young children may suffer from spasmodic attacks of 
dyspnea — the manifestation of the disease in the adult. With asthma 
in the child, regardless of age, there is almost invariably an association 
of bronchitis. In some the nervous phenomenon of spasm predomi- 
nates with little bronchial involvement. In others there is consider- 
able bronchitis, with slight, moderate, or intense spasm. In the case 
of the infant and very young child the term "capillary bronchitis " has 
been given to two distinct conditions. In one there is an acute spas- 
modic bronchitis, and in the other an acute pneumococcus infection of 
the lungs without localization. In acute asthmatic bronchitis the 
mode of onset, the lesions, and the fever are all as found in acute 
simple bronchitis. The bronchial spasm, however, differentiates the 
two forms from two standpoints: First, the respiration in the asth- 
matic type is very rapid — I have repeatedly seen it at 80 to 100; 60 is 
the rule. Secondly, the chest signs are most dissimilar. In the spas- 
modic cases there may be an entire absence of, or very feeble, respira- 
tory murmur, with inspiration short and squeaking in character, while 
the expiration is prolonged and accompanied by fine sibilant rales. 
These signs may be localized in one lung or a portion of a lung, or may 
occur in both lungs, as I have observed time and again, the same aus- 
cultatory signs occurring over the entire chest. There is but little 
action of the respiratory muscles; the chest appears held in fixed posi- 
tion. The dyspnea may be extreme, and the child suffers from air- 
hunger. Both the entrance and exit of air are impeded. Cyanosis, 
profuse perspiration, and marked prostration are apparent if the attack 
is prolonged. 

Percussion elicits hyperresonance or tympanitic dulness. This 
type of bronchitis may occur in the youngest infant. I have older 
children as patients who always have the spasmodic condition when 
there is a bronchitis. 

Etiology. — In asthmatic infants and children there is an undoubted 
gouty (lithemic) diathesis. Not only are these children subject to 



ACUTE SPASMODIC BRONCHITIS (BRONCHIAL ASTHMA) 317 

bronchitis of the spasmodic type, but they also have or may have at- 
tacks of croup, eczema, cycHc vomiting, periodic fever, and periodic 
intestinal crises, with or without fever, and with or without gastric 
crises. I have under my care a patient who suffered intensely from 
eczema when an infant and who later developed cyclic spasmodic 
bronchitis of a very severe type, usually combined with spasmodic 
croup and cyclic vomiting. This child kept her physician father very 
busy. When she was not doing one turn, she was doing another, and 
all came without warning. The child was of a markedly gouty an- 
cestry. I have had other cases as pronounced as this one. Most 
important dietetic factors in these cases are fat and sugar, particularly 
cow's milk-fat and cane-sugar. These patients during the asthmatic 
attack will develop the acetone breath, but not to the degree that is 
seen in cyclic vomiting (true acidosis). 

Illustrative Cases. — Case 1. — A girl eight years of age was brought to me 
with the history of an attack of asthmatic bronchitis every month for several 
years. The asthma was not severe. It was present at the onset of the at- 
tack, and lasted for perhaps twenty-four hours. The bronchitis usually cleared 
up in about five days. She had spent but little time in New York because of her 
so-called frequent "colds." Her mother brought the child to me in view of a 
contemplated change of residence. In Florida and lower California, where the 
patient had passed the winter, the attacks had occurred, but were mild in character. 
As soon as she returned home the attacks returned, keeping her from school for one 
week out of every four or five. In taking the personal history the matter of 
adenoids and tonsils was mentioned, when the mother hastened to inform me that 
the adenoids and tonsils had been removed twice, thus demonstrating that they 
were not a factor in the case. The child had never suffered from rheumatism or 
cyclic vomiting. Aside from revealing a mild secondary anemia and slight 
emphysema, the physical examination proved negative. The family history 
disclosed that all the child's antecedents on both sides, for three generations, had 
suffered either from rheumatism or gout. Her mother had been a life-long 
sufferer from rheumatism. Upon close questioning, it was found that the child's 
diet consisted of red meat twice daily; she disliked vegetables, took cereals only 
when covered with sugar, and drank milk only when two teaspoonfuls of sugar 
were added to each glass. She had candy and cake ad libitum. She was recovering 
from an attack of bronchitis when I saw her, and was taking an expectorant cough- 
syrup. This was discontinued, red meat was permitted but twice a week, the 
sugar was largely reduced, saccharin being used in the milk to satisfy the abnormal 
craving for sweets. She was bribed by the mother to eat green vegetables and 
cereals. The desserts consisted largely of stewed fruits flavored with saccharin. 
Candy, cake, and pastry were forbidden. She was given 4 grains of the salicylate 
of soda (wintergreen) three times daily for five days, which was followed by 10 
grains of the bicarbonate three times daily for five days; then for five days there 
was no medication. This treatment was continued for six months. During 
the following six months the salicylate and the bicarbonate of soda were given but 
five days each out of each month. During the entire year but one mild attack of 
bronchial asthma occurred. 

Case 2. — A most striking case of periodic asthmatic bronchitis occurred in a 
boy nine years of age. The father had had inflammatory rheumatism. Of the 
mother's family, the grandmother was an invalid with rheumatism and the grand- 
father was troubled slightly with it. 

The boy was pale, but well nourished, weighing 68 pounds. He was very active 
mentally. He had had chicken-pox and one attack of tonsillitis. The blood 
examination showed 78 per cent, of hemoglobin, 5,500,000 red cells, and 8,000 
leukocytes. The urine was negative. During the previous year he had had a 
great many attacks of asthmatic bronchitis. The mother stated that they occurred 
once every three or four weeks. Previous to this time there had been very frequent 
colds — so many that the boy's attendance at school had been practically nil. The 
mother had discovered that sugar did not agree, and very little had been given. 
He was very fond of red meat, however, and wanted it three times a day. He was 
given the meat twice a day. 



318 THE PRACTICE OF PEDIATRICS 

A liberal diet of green vegetables, fruits, milk, and cereals was ordered. In 
addition, eggs or bacon were to be given for breakfast, red meat three times a week, 
poultry three times a week, and fish once a week. Sugar was excluded absolutely, 
saccharin being used. Aspirin in three-grain doses was given after each meal, 
with five grains of bicarbonate of soda. 

This was the treatment for three months, during which term there was one 
attack of the asthmatic bronchitis. This responded to ipecac, antipyrin, and 
sodium bromid. Other than one or two slight colds, the boy has experienced no 
trouble during the past winter. He has lost but little time at school. At the end 
of seven months he had gained seven pounds in weight. 

The bicarbonate and aspirin were given continuously for three months. Since 
then they have been given alternately, each for five days, i. e., 3 grains of aspirin 
three times daily for five days, then 5 grains of bicarbonate of soda twice daily for 
five days. 

Cases Due to Direct Irritation.- — In this class belong comparatively 
few, notably those in which the paroxysm occurs independent of bron- 
chitis, but as a result of direct irritation from the pollen of plants or the 
odors of animals or flowers, the irritant producing a condition known as 
''hay-fever/' as well as the associated asthmatic condition. Hay-fever 
is rarely seen in children under five years of age. 

After several attacks of asthma associated with bronchitis, what is 
sometimes called a true asthma results; i. e., through the direct irrita- 
tion, as just mentioned, or through the peculiar susceptibility to odors, 
such as those from cats or horses, or otherwise reflexly because of the 
presence of abnormalities in the upper respiratory tract, the habit 
becomes once established and thereafter but very little irritation appears 
necessary to precipitate an attack. While these seizures may occur 
without clinical bronchitis, in not one of them will the bronchi be found 
normal, and the intolerance for the intense carbohydrates is as great 
in the cases in which clinical bronchitis is in evidence. 

Treatment. — The management of bronchial asthma consists in care 
during the attack, and the interval treatment, the latter being by far the 
more important. In infants and young ^'runabouts" with this type of 
trouble there is usually considerable bronchitis, and this requires our 
attention. I have found, in addition to the usual laxatives,— calomel 
or castor oil, — that a combination of syrup of ipecac, antipyrin, and 
bromid of soda gives the most prompt results as far as internal medica- 
tion is concerned. For a child six months of age the following prescrip- 
tion has been found useful: 

I^ Syrupi ipecacuanhse gtt. xviij 

Antipyrinse gr. vj 

Sodii bromidi. gr. xviij 

Syrupi rubi idsei 5 v 

Aquse q. s. ad gij 

M. Sig. — One teaspoonful every two hours — six doses in twenty-four 
hours. 

For a child one year of age : 

I^ Syrupi ipecacuanhse gtt. xxiv 

Antipyrinae gr. xij 

Sodii bromidi gr. xxiv 

Syrupi rubi idsei 5"v 

Aquse q. s. ad §ij 

M. Sig. — One teaspoonful at two-hour intervals — six doses in twenty- 
four hours. 



ACUTE SPASMODIC BRONCHITIS (BRONCHIAL ASTHMa) 319 

For a child from two to three years of age : 

I^ Syrupi ipecacuanhse gtt, xxxvj 

Antipyrinse gr. xviij 

Sodii bromidi gr. xxxvj 

Syrupi rubi idsei 3y 

Aquae q. s. ad 5i,i 

M. Sig. — One teaspoonful in water at two-hour intervals — six doses in 
twenty-four hours. 

In addition, the child will often be greatly relieved by stimulant 
inhalations, as described under Spasmodic Croup (p. 287). If the con- 
dition is urgent, the inhalations may be given for thirty minutes with 
thirty minutes' rest. 

Mustard, in the proportion of one part of mustard to two parts of 
flour (p. 312), so applied as to envelop the entire thorax, will often re- 
lieve the spasm sufficiently to reduce the respirations from 10 to 20 a 
minute. The mustard should remain on long enough to redden the 
skin, and should not be repeated oftener than once in four hours. 

The cold-air treatment in bronchial asthma is contraindicated, 
regardless of the age of the patient. Warm, moist air at from 68° to 
70°F. is best. A sudden blast of cold air may be sufficient to increase 
the severity of the paroxysms to a marked degree. Ventilation, how- 
ever, is a necessity in these cases. The best means of obtaining it is 
by the use of two rooms, one of which may be aired while the other is 
occupied. Before the child is changed to the aired room, its tempera- 
ture should be raised to that of the other. 

In older children after the fifth year the bronchial spasm may be 
considerable, and more active measures may be required to furnish 
temporary relief. Here the methods usually employed for the same pur- 
pose in adults may be brought into use. A few whiffs of chloroform 
will often be effective. Fumes of nitrate of potash paper will sometimes 
be of service. At this age, also, a combination of antipyrin and bromid 
of soda may be brought into use. For a child from five to ten j^ears of 
age 3 grains of antipyrin with from 6 to 10 grains of bromid of soda, 
repeated in two hours, will often obtain a cessation of the paroxysm. 
As soon as the spasm subsides the sedatives should be discontinued. 
I have never found it necessary to give morphin hypodermatically or 
otherwise in these cases. In a very severe case, in a girl eight years of 
age, a combination of antipyrin and codein in full dosage was required 
to control the paroxysms. She was given 3^^ grain of codein and 4 
grains of antipyrin at two-hour intervals until three doses had been 
given. 

In the urgent cases La Fetra advises the use of adrenalin hypo- 
dermically. Five minims of a 1 : 1000 solution is given to a child from 
two to six years of age. A diet with low fat formula, not over 2 per 
cent., should also be used. 

Before instituting interval treatment all growths in the rhino- 
pharynx should be removed, and such abnormalities as hypertrophies 
or deformities should be corrected, and the child given a suitable 
living regime. 



320 THE PRACTICE OF PEDIATRICS 

Interval Treatment. — For the bottle-fed this consists in reduction of 
the sugar to one-half the amount suitable for the age, and the use of 1 
grain of bicarbonate of soda for each ounce of the milk food given. 
The bowels must be kept properly open, although constipation or in- 
testinal toxemia has never appeared to me to be an important factor in 
asthmatic children. 

The interval treatment for older children is most important, for by 
it we are able to postpone the attacks. These cases, as I have indi- 
cated, are usual in lithemic subjects, and the scheme of management 
followed out is the same as for rheumatism, chorea, recurrent bronchi- 
tis, and cyclic vomiting. Sugar is reduced to a minimum, and red meat 
is given not oftener than every second day, and then only in moderate 
amounts. The child's proteid nutrition is maintained by the use of a 
high-proteid cereal, such as oatmeal, and purees of dried peas, beans, 
and lentils. The eating of green vegetables is encouraged. Food 
between meals is forbidden. Fruits are used in moderation and an 
active outdoor life is encouraged. At bedtime the child is given a 
brine bath (p. 780), followed by a vigorous dry rub. The mother or 
attendant is instructed that one bowel evacuation daily must be in- 
sured. The medication consists of bicarbonate of soda, from 5 to 10 
grains a day for five days, alternating with the salicylate of soda 
(wintergreen) in doses of from 3 to 5 grains three times a day. This is 
continued for a month or two until its effect in preventing a recurrence 
is noted. If the salicylate of soda disturbs the digestion, the same 
quantity of aspirin may be given. The further continuation of the 
medication depends upon the effect already produced. Usually in two 
months the salicylate may be given in smaller doses. Interrupted 
medication, however, should be continued for several months. When 
my cases with a bad family history have been relieved, I continue the 
diet permanently, giving the medication for but five or ten days and 
then omitting it for sixty or eighty days, then giving it again for a short 
time, and continuing thus as long as may be thought best for the 
individual. 

PNEUMONIA 

Pneumonia is an infective process, due to bacterial invasion, seen 
with the greatest frequency in the young. The influence of cold, which 
is that of shock, producing a lowered resistance, temporarily makes the 
individual unusually susceptible to the infecting agencies, which are 
ever present. On account of the different ways in which these infect- 
ing agents manifest themselves in the lungs, two types grossly are pro- 
duced — hroncho- or catarrhal pneumonia, and lobar or fibrinous 
pneumonia. 

Lobar Pneumonia 

Lobar pneumonia is an acute infection of the lungs, primary in 
character. It may occur at any age. My youngest patient was three 
days old. Until the second year this type occurs less frequently than 
the catarrhal form. 



PNEUMONIA 321 

Etiology. — The influence of cold is to produce a lowered resistance. 
Exposure may therefore play a part. The disease occurs with greatest 
frequency during the winter and spring months. 

Bacterial Etiology. — The specific etiologic factor in the production of 
lobar pneumonia is the pneumococcus of Frankel (Diplococcus pneu- 
moniae; Micrococcus lanceolatus). The experimental evidence needed 
to prove this fact has recently been supplied by Lamar and Meltzer 
(Journal of Experimental Medicine, February, 1912), who showed that 
intrabronchial injection of pure cultures of Diplococcus pneumoniae in 
dogs produced pneumonia of the lobar type only, corresponding both 
grossly and microscopically to that lesion as found in human beings. 

The pneumococci are found in large numbers in the sputum, but 
they invade the blood-stream in only about 13 per cent, of the cases, 
according to the studies of Otten (Jahrbuch ftir Kinderheilkunde, 
1909, Ixix) and Churchill (Transactions Amer. Pediatric Society, 1910), 
a much smaller proportion than is found in adults. Moreover, about 
half of the cases with positive blood-cultures recovered. 

In some cases the disease is caused by the pneumobacillus of 
Friedlander. 

Predisposition. — ^Lobar pneumonia in the young is not a disease of 
the weak. This type of child is the subject of bronchopneumonia. 
It is usually the strong and vigorous child who develops lobar 
pneumonia. 

Pathology. — The most apparent effects of the disease are those pro- 
duced in the pulmonary tissue, where there is an exudative inflamma- 
tion which progresses through four well-recognized stages, to which are 
applied the terms — (1) Congestion; (2) red hepatization; (3) gray 
hepatization, and (4) resolution. These stages are not always clearly 
defined; and not infrequently, at postmortem, neighboring portions 
of a lung simultaneously present the appearances characteristic of two 
or more stages of the same inflammation. Congestion, consolidation, 
and resolution have, however, a very constant order of occurrence, 
and this is well understood when one considers the exudative nature of 
the inflammatory process. 

In the primary stage of congestion the involved portion of the lung 
is the seat of active hyperemia and edema, and becomes darker in color 
and acquires increased consistence. The alveolar capillaries are tur- 
gid, and the epithelial cells lining the air-spaces are swollen. In the 
stage of red hepatization a well-marked exudation into the alveolar 
spaces ensues. The exudate consists chiefly of fibrin, red blood-cells, 
leukocytes, and desquamated epithelial cells. The involved lung 
structure thus becomes practically solid and roughly resembles liver. 
The pleurisy, the swelling and heaviness and the packing of the alveoH 
are all most marked during the red stage. During the stage of gray 
hepatization the alveoli become choked with additional exudate, which 
consists chiefly of leukocytes, the blood-vessels undergo compression, 
and the lung mass becomes swollen and heavy and assumes a gray 
appearance. The pleura shares in the inflammation and at this period 
21 



322 THE PRACTICE OF PEDIATRICS 

is coated with more or less fibrinous exudate. The stage of resolution 
marks the change by which the air-cells are relieved of their burden and 
the normal circulation is restored. This process is essentially one of 
autolysis, involving disintegration of the fibrin meshes in the exudate 
and degeneration of the masses of leukocytes and desquamated epithe- 
lial cells. Large phagocytic cells engulf the degenerating leukocytes 
as well as all other granular particles and carry them away in the 
lymph stream. Much of the liquefied exudate is coughed up directly. 

Eventually, the normal lung structure is restored except in those 
instances in which the occurrence of interstitial exudate has facilitated 
the development of abscess or gangrene, or the usual dry pleurisy has 
been superseded by inflammation of the purulent type — empyema. 

In cases of typical lobar pneumonia the pneumococcus present in 
the circulating blood may give rise to localized abscesses or such fatal 
complications as peritonitis and meningitis. 

Localizations of the Lesions. — Orth's figures for the localization of 
lobar pneumonia are — 

52 per cent, for the right side. 
33 per cent, for the left side. 
15 per cent, for both sides. 

In 217 cases (Koplik) the right lung was involved in 124 and the 
left in 93; the upper right lobe in 74, the upper left in 35, and the upper 
lobe of either lung in 109 cases, as against 100 cases for the lower lobes. 
Mason* in an interesting Roentgen ray study of the lungs in lobar 
pneumonia has demonstrated that, in the silent pneumonia usually 
called central pneumonia, the lesion is not central but peripheral and 
that voice and breath sounds are only present when there is evenly 
developed involvement extending from the pleural surface to the 
hilum, supplying a medium which carries the sound from the trachea 
and large bronchi. 

As a rule, but a portion of one lobe is affected. An entire lobe may 
be involved, but never, in my experience, has there been found a com- 
plete consolidation of an entire lung. In double pneumonia a portion 
of one or more lobes in each lung will be involved. 

Symptoms. — The onset of the disease is sudden, with fever and 
rapid respiration, which may be found ranging from 40 to 60. There 
may be cough. The temperature is variable — over 102° and under 
105 °F. The pulse is rapid — 130 to 160 — and there is considerable 
prostration. These are the only symptoms distinctly indicative of 
lobar pneumonia. 

Vomiting, convulsions, stupor, and chill, to which much attention 
is given by writers, may and do occur with many other diseases, and 
may and do occur in some cases of pneumonia; thus, in my own cases 
convulsions have ushered in the disease in 2 per cent. ; vomiting in less 
than 10 per cent. ; chill in about 5 per cent. Loss of appetite, coated 
tongue, and drowsiness are, of course, noted, and these are all present 
in dozens of ailments. 

* Am. Journal Diseases of Children, vol. xii, pp. 188-189. 



PNEUMONIA 



323 



The prostration is most marked for the first forty-eight hours. 
After this time the organism appears to adjust itself to the changes 
induced by the infection. During the first or the second day of ilhiess 
the temperature becomes estabhshed at a high point, — 103° to 105°F., 
— where it remains, usually with slight variation in a recovery case, 
until the crisis. This steady high range of temperature (see Fig. 41) 
is not always followed out by the disease. The fever may fluctuate 
considerably. In an eight months' old child the temperature was that 
of a typical malaria, 99°F. in the morning, 104° to 105°F. in the late 
afternoon. The crisis occurred on the eighth day, and the child was 
promptly well. Thorough examination from every standpoint failed 
to show other than a lobar pneumonia. 

The respiration per minute depends upon the amount of lung 
involved, the virulence of the infection, and the age of the patient. In 



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Fig. 41. — Temperature chart, lobar pneumonia. 

children under two years of age, from 60 to 80 respirations per minute 
are not at all unusual. In older children the respiration is less rapid, 
often not exceeding 60 per minute. The pulse in young children is in 
like manner more accelerated — a range from 150 to 180 is not unusual, 
while in children after the third year the rate may not be above 160. 

Duration of the Attack. — The duration is variable. In the event of 
mild infection, probably associated with good resistance, I have had 
these patients make the crisis on the third day, even before the 
physical signs were positive. Such cases are by some authors said to 
represent the abortive tj^pe. 

In the average recovery case the crisis occurs from the fifth to the 
ninth day. A crisis delayed beyond the ninth day means a very 
serious infection and a very grave prognosis. I have had recovery 



324 THE PRACTICE OF PEDIATRICS 

cases in which the crisis did not occur until the eleventh day. In one 
instance the crisis transpired in the thirteenth; and in another, the 
fifteenth day. 

Unfavorable Symptoms. — The most unfavorable symptom in lobar 
pneumonia is a low temperature in the presence of the other character- 
istic signs — rapidity of respiration, rapid pulse, and prostration. 

Illustrative Case. — I was called by a practitioner in a New York suburb to see a 
case of pneumonia that disturbed him greatly, although it was impossible to make 
the parents understand that the child was severely ill. There was no elevation of 
the temperature — in fact, it was slightly subnormal. The child, who was ten 
months old and had been previously healthy, showed marked pallor and prostra- 
tion not unlike that presented by an acute gastro-intestinal intoxication case, 
such as is frequently seen in summer. The respiration was about 40 and the pulse 
was rapid and weak. There was nothing to account for the illness other than a 
frank consolidation of the right lower lobe. I made a fatal pipgnosis, recognizing 
the probability of death in a few hours. The child died twelve hours after my 
visit. 

In this case the child was overwhelmed by the pneumococcus infection, so that 
fever or any reaction was impossible. 

Cases of this kind in vigorous children are rare. In athreptics and 
those older children who suffer from malnutrition or who develop 
pneumonia after a previous exhausting disease the low temperature 
range — 100° to 102°F. — is not at all unusual. With it will often be 
associated petechial skin eruptions. In such instances the prognosis 
is most unfavorable. 

Tympanites. — The development of marked abdominal distention 
is a symptom of grave import, indicating a high grade of toxemia. 
Further, the distention interferes not a little, mechanically, with the 
already embarrassed respiration. 

Vomiting and diarrhea are usually occasioned by improper feeding. 
Uncorrected, they add to the dangers of the patient. 

Stupor and delirium are cerebral evidences of the systemic toxemia, 
and while they indicate a severe infection, their presence is more con- 
fusing in a diagnostic sense than an indication of danger to the patient. 
The symptoms are more active, particularly the temperature manifes- 
tation, when the right apex is involved. Such a localization, however, 
has no influence on the prognosis. 

Delayed Crisis. — Every day after the ninth, without the critical 
drop, adds to the danger of the patient. 

Lobar pneumonia is rarely fatal before the ninth day. Deaths, 
of course, occur earlier, due to the severity of the infection, but this is 
very exceptional. 

Among eight fatal cases at the New York Infant Asylum in a six 
months' service, two died on the eighth day, two on the ninth, two on 
the twelfth, and one on the twenty-first day of the disease. In the 
cases of long duration we have to deal with a condition in which the 
individual is not able to manufacture sufficient antitoxin to destroy 
the infecting agent or agents, and the question naturally arises, will he 
be able to do so? 

Complications. — The advent of a complication adds a more serious 
aspect to the disease. A complication may appear at any time during 



PNEUMONIA 325 

an attack, and change what appears to be a favorable case into one of 
the greatest gravity. 

The comphcations that have occurred under my observations are 
as follows: myocarditis, pericarditis, pneumococcus-meningitis, pneu- 
mococcus-peritonitis, empyema, peri-arthritis, otitis, pulmonary ab- 
scess, and pulmonary gangrene. 

Myocarditis. — In very severe infections in which the temperature 
has been high, a decided irregularity of the heart action develops. 
There may be no cyanosis or other indication of general heart failure. 
The first sound will be weak and incomplete. 

Pericarditis. — Fluid, serous or purulent, is more often discovered at 
the autopsy than recognized during the illness, and more common in 
left-sided empyema. I have seen cases postmortem which showed the 
pericardial sac filled with pus and fibrin, and the heart surrounded with 
the latter so as to be scarcely recognized, although no cardiac sign had 
been present during life, other than that both sounds were defective. 

Meningitis of pneumococcous origin (p. 550) is not at all unusual 
among hospital and asylum patients. An invasion of the meninges 
by the pneumococcus produces characteristic symptoms (p. 550) quite 
apart from the usual manifestations of pneumonia, so that recognition 
of this complication is readily made. Further, when the meninges are 
attacked, the resulting symptoms are very active. At once there is 
slow, irregular respiration, slow, irregular pulse, stupor from which the 
child may not be aroused, and change in the pupils. 

Peritonitis. — Persistent distention of the abdomen, with evident 
pain on pressure, and obstinate constipation are indications of acute 
peritonitis. In ni}^ hands these cases — five in all — have all been fatal. 

Empyema (p. 353) may develop during the pneumonia, in which 
case the chief manifestation will be a change in the physicial signs — the 
bronchial breathing and bronchial voice changing suddenly to weak, 
distant bronchial sounds, associated with flatness on percussion. 

Empyema, however, is more apt to follow a day or two after the 
crisis than to occur during the active stage of the disease. It is a com- 
plication that I have seen in a large number of cases in different stages 
of the disease, and the possibility of its development should never be 
forgotten. 

Peri-arthritis will be made evident by pain and swelling of a joint, 
most frequently the shoulder or elbow. 

Otitis is often overlooked because of the absence of pain to locate the 
trouble. It often passes unrecognized until a rupture of the drum 
occurs, the fever being accounted for by the lung disease. 

In every disease of infectious origin the ears should be subjected to 
a daily otoscopic examination. 

Acidosis in Lobar Pneumonia. — A child eighteen months of age 
developed fever, prostration and rapid respirations, the typical 
hyperpnea of acidosis, active deep urgent breathing, in marked contrast 
to the usual quiet superficial sighing, though rapid, respirations of lobar 
pneumonia. The child showed acetone + + + in the urine and the 



326 THE PRACTICE OF PEDIATRICS 

acetone breath was very noticeable. The chest signs were sufficient 
for a diagnosis of pneumonia, but the child died from acidosis. 

Prognosis. — The prognosis in lobar pneumonia in private cases 
depends considerably upon whether the patient is under private care 
in a sensible family, or subject to ignorant surroundings. If the phy- 
sician may have the right support the mortality is very low — from 2 to 
3 per cent. Among the ignorant and careless it will be higher — from 5 
to 10 per cent. — approaching the mortality in hospitals and children's 
institutions. The high mortality in children's hospitals is due more to 
the wretched condition in which the patient arrives than to peculiarly 
severe features of the disease. In infant asylums and children's insti- 
tutional homes a lack of resistance to disease is the rule, and pneu- 
monia affords no exception. 

Diagnosis. — The diagnosis in infants and young children is sur- 
rounded with few difficulties. The sudden onset of illness, with high 
fever, rapid respiration, dilatation of the alse nasi, expiratory grunt, 
and rapid heart action, are objective signs of real significance. 

Consolidation of the Lungs. — This sign makes the diagnosis positive. 
The time of its appearance, however, is subject to considerable varia- 
tion. It may be present during the first twenty-four hours, and I have 
seen it repeatedly delayed to the fourth day. Rarely it will appear as 
late as the fifth day. In one case, showing very active symptoms 
otherwise, consolidation was not apparent until the seventh day. On 
the day the consolidation appeared crisis occurred. Cases of this type 
may go through the entire course of the disease and never show 
definite consolidation. Such pneumonia was formerly referred to as 
''central." Mason of New York has demonstrated by Roentgen ray 
studies that these cases are really marginal pneumonia. There is no 
doubt but that a pneumococcous infection of the lung may exist for 
several days and run its entire course without the process ever going 
on to consolidation, demonstrable by our usual means of examination. 
We know that this is possible in the two or three day cases represent- 
ing clinically the so-called abortive type. 

The Physical Signs. — Auscultation. — As already indicated, auscul- 
tation may never reveal a sign of the disease other than harsh or sono- 
rous breathing. As a rule, the infiltration of the air-cells will develop 
sufficiently from the second to the fourth day to produce bronchial 
breathing and bronchophony. 

Over the consolidated area fine pleuritic friction rales will usually 
be heard at the height of inspiration when the consolidation makes its 
appearance. In practically every case of lobar pneumonia the pleura 
over the consolidated surface will be found dry, injected, and often 
showing a very fine exudation. 

Percussion. — Percussion will show dulness, depending in degree and 
extent upon the nature and distribution of the lesion. Absolute dulness 
will be present only over the consolidated area. 

The chief value of percussion is in differentiating the presence of 



PNEUMONIA 327 

fluid from extensive fibrinous exudation, a condition sometimes desig- 
nated as pleuropneumonia. 

Palpation. — Palpation is of little value in children, and reveals 
nothing that may not be learned through auscultation and percussion. 

Vocal Fremitus. — In diagnosing considerable exudations of fluid in 
the pleural cavity, and pneumothorax, the absence of vocal fremitus 
may furnish corroborative evidence. 

Differential Diagnosis. — ^Lobar pneumonia is to be differentiated 
from pneumonia of the catarrhal type, from acute pleurisy with massive 
output of fluid, and from similar cases in which the fluid is less in 
amount. The differentiation between the lobar and bronchopneu- 
monia will be found on p. 336. 

Pleuritic Effusion. — When there is a fluid, pleuritic exudate sufli- 
cient to fill the entire cavity, with the fluid under pressure over a com- 
pressed and consolidated lung, signs will be transmitted to the chest- 
wall, closely resembling the signs of frank consolidation. Thus there 
will be bronchial breathing and bronchophony of a very intense char- 
acter over the entire involved side anteriorly and posteriorly, at both 
the apex and the base. Repeatedly in consultation I have found these 
signs interpreted by the attending physician as meaning a complete 
consolidation of the lung. It is to be remembered that a lung is never 
entirely consolidated in acute pneumonia. Furthermore, in the 
presence of a massive fluid exudate percussion will elicit flatness over 
the entire surface. When the process is located on the left side, the 
heart displacement indicates the presence of fluid in the pleural 
cavity. 

In cases of effusion, finally, there is an absence of friction-sounds and 
likewise of rales. When doubt exists, exploratory puncture should 
always be made. Fluid in lesser amounts is indicated by diminished 
respiratory sounds, localized flatness, the absence of mucous or pleuritic 
rales, and displacement of the heart if the exudation is in sufficient 
amount. Only in cases in which the pleural cavity is absolutely filled 
with fluid do we find the voice and respiratory signs of frank lobar 
pneumonia. 

Blood-findings in Lobar Pneumonia. — (See p. 397.) 

Treatment. — ^Lobar pneumonia runs a limited course, with a strong 
tendency to recovery. It is a disease which children bear well under 
proper management. There is no specific treatment, and our efforts 
in restoring the patient to health are supportive only. 

When a child is stricken with lobar pneumonia, we know that his 
physical strength is to be severely tested, and our first effort should 
be to place him in such a position that he may to the best advantage 
cope with the enemy. In order to do this every detail of his daily 
life should so be arranged as to assist all the organs of the body most 
favorably to combat the changed conditions produced by disease. 
Telling the mother what to do for the fever and writing a prescription 
for a cough mixture is a most careless method, worthy of the prescrib- 
ing apothecary rather than a physician. A proper regime must be 



328 THE PRACTICE OF PEDIATRICS 

established as soon as the child becomes ill. The bowel function, the 
room-temperature, ventilation, and sleep, as well as special medication, 
are all to be considered. The child must be kept as comfortable as the 
conditions allow, and his comfort demands the avoidance of everything 
causing restlessness or irritability, which throws more work upon the 
heart and lessens the patient's resistance to the disease. 

Cold Air. — In strong robust children the cold air treatment is to 
be advised. These patients unquestionably do better with the win- 
dows wide open day and night. In such an atmosphere the respiration 
is slower, the heart action is stronger, and the patients are much more 
comfortable, sleep better, and make a more satisfactory convalescence. 
A woolen hood and suitable woolen clothing should be worn. 

The Sick-room. — In cases or in families in which the cold air treat- 
ment is not practicable, the temperature of the room should be kept at 
61° to 65°F. both day and night. Wide fluctuations in the temperature 
should not be allowed. A large room, if at hand, should always be 
selected, and there must always be direct communication with the 
open air by an open window. The child should be kept in the crib, 
and not held on the lap of the mother or nurse. 

Quiet should be maintained in the sick-room, only those in atten- 
dance upon the patient being admitted. A sick-room is no place for 
visitors and curious persons. Their presence annoys the child and 
takes away a certain number of strength units, which may determine 
the outcome of the case. The advantages of the cold room or roof 
treatment in this respect are obvious. 

The Clothing. — The clothing should be the usual night-clothing. 
I have long since discarded the oiled-silk jacket or any special form of 
covering. The oiled-silk jacket or a jacket made of cotton wadding is 
very easy to put on, but very difficult to take off with safety; further, 
it has a tendency to elevate the temperature of the patient, it makes 
him uncomfortable, particularly during convalescence, and prevents 
the free action of the skin. These objections, with the fact that there 
is no rational argument for such wrappings, are sufficient to condemn 
them. 

The Bowels. — There should be a standing order with the nurse or 
mother for an enema to be given if the bowels do not move once in 
twenty-four hours. One-half to one grain of calomel in doses of 3^ 
grain every hour is usually of considerable service. In a case in which 
there is very high fever I often order this dosage repeated every three 
or four days. 

Counter irritation. — Counterirritation of the skin is of little service 
in lobar pneumonia. Early in the attack, when there is pain, a mus- 
tard plaster, — one-third mustard and two-thirds flour, — mixed to a 
paste, spread on cheese-cloth, and placed over the involved area for 
a few moments, will give signal relief and may be repeated at intervals 
of from four to five hours. This form of counterirritation is also use» 
ful in convalescence in delicate children when the lung clears slowly, 
and examination reveals feeble breathing and many mucous rales. In 



PNEUMONIA 329 

such cases two or three apphcations daih' until the lung clears will 
suffice. Each application should be maintained until the skin is well 
reddened. If reddening does not occur within ten minutes, the mix- 
ture of mustard and flour should be made stronger — one-half mustard 
to one-half flour. In a few cases of delayed resolution two dry cups 
daih^, applied directly over the involved areas, have been of much 
service. 

The Diet.— See Diet in Illness, p. 109. 

Mana^gement of Pyrexia. — Whether or not antipyretic measures are 
to be used, and the nature of the antipyretic to be advised, depends 
upon the case and the famih' possibilities relating to care and nursing. 
One child will bear a temperature without inconvenience which would 
seriously compromise the chances of recover}^ of another, so that the 
thermometer is not a sufficient guide unless the effect of the fever upon 
the patient be considered. Some children will be delirious and restless 
and will need antipj'retic treatment when the fever is at 103°F. A 
temperature of 104°F. rarely needs interference. A rise of 1°F. 
usually means an increase of 20 to 30 heart-beats per minute. In 
lobar pneumonia I prefer that the temperature should not go above 
105°F., even if at the time the child shows but little inconvenience. 
Such a temperature means an unnecessary increase in the amount of 
work required of the heart, which itself demands relief in such an 
emergency. 

Hydrotherapy. — Cold water, intelligently applied, is the best means 
of reducing fever. The water may be used either in the form of a 
sponge-bath or a cool pack. The sponge-bath (p. 780), repeated at 
intervals of from two to four hours, suffices in a few cases in which the 
temperature is readilj' influenced. As a rule, the cool pack (p. 777) 
will be required, especialh^ if the fever is particularh^ high. The 
sponge-bath, while not controlling the fever as well as does the pack, 
possesses the advantage of safety even when administered by the most 
ignorant. The procedure reall}^ amounts to nothing more than spong- 
ing the entire body with cool water or alcohol and water. The cool 
pack requires a trained nurse or an intelligent mother, either of whom 
should be instructed hy the physician as to its use. When cool water 
is properly applied, and the packs or baths agree, prompt improve- 
ment in the immediate symptoms foUow^s. The child, previoush^ rest- 
less and perhaps delirious, falls into a quiet sleep; the temperature falls 
two or three degrees, the pulse becomes slower and fuller, and the res- 
piration less frequent. I have never seen a carefully given pack or 
bath do harm to a child. In fact, the water is most grateful to the 
patients, who, when old enough, often ask to have the towel made 
cooler when it becomes warm and dry from the heat of the bod5^ 

Heart Stimulants. — A child must never be given a heart stimulant 
simply because he has pneumonia. Heart stimulation is usually em- 
ployed too early in the attack. Only when the pulse shows signs of 
weakness, great rapidity, irregularity, or reduced volume, has the 
time arrived for stimulation. For a very rapid pulse, i, e., over 150, 



330 THE PRACTICE OF PEDIATRICS 

tincture of strophanthus has answered better in my hands than any 
other form of stimulation. For a child from six months to one year 
old, I order one drop every two hours — at least six doses in twenty- 
four hours; for a child from one to three years old, one or two drops 
at intervals of two hours — at least six doses in twenty-four hours; for 
a child of three years or over, two or three drops at intervals of two 
hours — at least six doses in twenty-four hours. If the case is a very 
serious one, the strophanthus may be given every two hours during 
the entire twenty-four, although if the conditions permit, it is better 
to disturb the patient as infrequently as possible during the night. 

When the pulse is irregular and intermittent, with reduced volume, 
strychnin is the remedy. To a child from six months to a year old 
Moo grain is to be given every three hours — six doses in twenty-four 
hours; from the first to the second year, J^^oo grain at three-hour in- 
tervals — six doses in twenty-four hours; after the second year, 3^50 
grain may be given at intervals of three or four hours — six doses in 
twenty-four hours. Children who are under strychnin medication 
should be carefully watched for signs of the physiologic effects of the 
drug, the first symptoms being an unusual susceptibility to sudden 
noise and a slight fibrillary twitching of the muscles of the face and the 
backs of the hands. Instructions should be given, when these symp- 
toms appear, to discontinue the drug until the next visit of the 
physician. I have repeatedly noticed these signs of the physiologic 
effects of the administration of strychnin, and they need cause no 
anxiety. They are actually necessary in order to get the full benefit 
of the drug. However, it is only in the most severe cases that this 
drug should be pushed to such an extent. 

When the circulation of the skin is deficient, involving coldness of 
the extremities and cyanosis, indicated by blueness of the finger-nails 
and lips, nitroglycerin is indicated. To a child under one year of age, 
3^00 grain may be given at intervals of two or three hours — six doses 
in twenty-four hours; to a child from one to three years of age, 3'^oo 
grain at three-hour intervals— six doses in twenty-four hours; after 
the third year, 3^f 50 grain at intervals of two or three hours — six doses 
in twenty-four hours. Nitroglycerin, if given in large doses, produces 
headache, of which older children will complain, while nurslings will 
show their discomfort by restlessness and crying. 

Caffein sodiosalicylate is also very useful in cases of this nature, 
and may with advantage be employed with the strychnin. The dos- 
age for a child from six months to one year is 3^^ grain. Camphor in 
the form of the oil of camphor is useful hypodermatically in the con- 
dition just described. It may be given in one to two grain doses and 
repeated in one to two hours. In collapse, 3^ooo solution of adrenalin 
hypodermatically, administered in dosage of from three to five drops, 
is of much use. 

Digitalis is rarely used as a heart stimulant for young children 
It disturbs the stomach and meets conditions much less satisfactorily 
than the remedies mentioned. The ammonium preparations are not 



PNEUMONIA 331 

employed, because their administration, even for a short period, in- 
variably interferes with nutrition by diminishing the digestive capacity. 

Alcohol is often prescribed too early. Many of my cases of pneu- 
monia in children pass through an entire attack without one drop of 
alcohol. Alcohol in any form should be avoided early in the disease. 
Later, when the case is doing badly, when the strychnin and strophan- 
thus, alone or in combination, fail, the alcohol may be given, and then 
it may be a life-saving means. It is indicated at this time because it 
sustains the patient when regular food assimilation is impossible, and 
at the same time stimulates the heart. Under one year of age I give 
from 8 to 30 drops of brandy, at two-hour intervals; from one to two 
years of age, 15 drops to 1 dram at two-hour intervals; over two years, 
1 to 2 drams at two-hour intervals. Patients who show profound sep- 
sis will require and consume an enormous quantity of alcohol without 
showing the slightest intoxicating effect. During my term as resident 
physician of the New York Infant Asylum a child fourteen months of 
^ge, ill with diphtheria, was given 4 ounces of brandy in twenty-four 
hours without showing signs of stupor or intoxication. 

Hypodermic Stimulation. — The use of hypodermic stimulation in 
■children is to be advised in an emergency, or when the stomach becomes 
intolerant, or when it becomes evident that drugs administered by 
mouth are not absorbed. If the dietetic means suggested are carried 
out, and if disturbing drugs, such as the ammonium salts, heavy 
syrups, etc., are omitted, there will rarely be any occasion to resort to 
hypodermic stimulation. When indicated, the doses suggested for the 
stomach may be given hypodermically, with the exception that alcohol 
should not thus be given in quantities greater than one-half dram of 
brandy or whisky at one time. 

Gavage. — Cases are encountered in which, for a time, on account of 
the profound toxemia, no food or medicine will be taken. In such in- 
stances the giving of stimulants and predigested food by means of 
gavage (p. 790), will be of material assistance. The milk used should 
be completely peptonized, and to it whisky, brandy, and. stimulating 
drugs may be added. The forced feeding should not be used oftener 
than once in four hours, and preferably only once in six hours. When 
thus given, the individual doses of the stimulants should be increased. 

The Murphy drip method of using a normal salt solution is of 
service in cases in which feeding difficulties are insurmountable. 

Specific Medication. — There is no drug known which will cut short 
or abort an attack of lobar pneumonia. Mercury in the form of large 
doses of calomel, quinin, salicylate of soda, and other drugs have no 
specific action. 

As previously stated, our efforts must be directed toward a conser- 
vation of the strength of the patient by placing him in the best position 
to cope with the disease. This management, combined with careful 
medication to meet special requirements as they arise, constitutes our 
treatment of lobar pneumonia, and has given us a death-rate of only 2 
per cent, in children under two years of age. During convalescence 



332 THE PRACTICE OF PEDIATRICS 

great care is needed in permitting the child to resume his usual habits 
of life, for in the matters of both food and exercise we must make 
haste slowly. 

Bronchopneumonia (Catarrhal Pneumonia) 

Catarrhal pneumonia is preeminently a disease of infancy. On ac- 
count of its large mortality, and because of its frequent occurrence as 
a complication of almost every other disease of infancy, it is one of the 
most formidable ailments which we are called upon to treat. The dis- 
ease is usually described as primary or secondary. Among the several 
hundred cases which have come under my observation, comparatively 
few — less than 5 per cent. — have been primary. Those described as 
primary usually follow a bronchitis — often a neglected bronchitis. 
The severity of the disease varies considerably, depending on the age 
and condition of the child, the nature of the infection, and the amount 
of lung involved. It is most fatal when associated with diphtheria, 
measles, and pertussis. 

Catarrhal pneumonia demands our most careful attention, not 
only on account of the delicate organs attacked, but because, unlike 
lobar pneumonia, scarlet fever, typhoid fever, and many other diseases 
of early life, this disease has no self-limitation, no cycle. While in 
treating the other diseases mentioned we are required only to assist a 
patient through the various stages, in case of catarrhal pneumonia we 
must do more, for here a cure is demanded. We are not aided by a 
tendency to time limitation. 

Etiology. — The cause predisposing to bronchopneumonia is the 
tender age of the patient, who, on this account, offers little resistance 
to the infection. Children debilitated from any cause are predisposed 
for a like reason. Whooping-cough and measles more than any other 
diseases predispose to bronchopneumonia. In a large number of fatal 
cases of marasmus and malnutrition, bronchopneumonia is the termi- 
nating illness. 

Bacteriologic Etiology. — The bacteriologic cause of bronchopneu- 
monia is not a specific entity. There are a number of microorganisms 
which may cause the disease, and in over 60 per cent, of the cases there 
is a mixed infection. This is true even in the primary cases. The 
Diplococcus pneumoniae (Frankel) is the bacterium most frequently 
present, but it is found in pure culture only about one-fourth as often as 
in combination with other organisms. The streptococcus comes next 
in order of frequency — three times more often in combination than in 
pure culture. The Staphylococcus aureus may be present alone, but is 
far oftener found with the pneumococcus or the streptococcus. The 
bacillus of Friedlander, either in pure culture or in mixed infection, is a 
rare cause of bronchopneumonia in children. Since bronchopneu- 
monia may be secondary to a variety of diseases, the causative organ- 
ism of the primary condition in a given case may be found in the pul- 
monary lesion. Thus B. diphtherise, B. influenzae, the Bordet-Gengou 
bacillus of pertussis, B. typhosus, B. pestis, B. anthracis, B. pyocya- 



BRONCHOPNEUMONIA (CATARRHAL PNEUMONIA) 333 

neus, or the meningococcus may be found associated with one or more 
of the pyogenic cocci. B. coli communis is a possible though very rare 
factor in this disease. 

Age. — A great majority of the cases occur in children under two 
years of age. Over one-half of these patients are under one year of age. 
After the third year bronchopneumonia is unusual except as a compli- 
cation of measles or pertussis. 

Pathology. — Bronchopneumonia almost invariably occurs as a 
sequel to acute bronchitis or one of the infectious diseases involving 
inflammation in the upper respiratory tract. Ordinarily the process 
begins as an inflammation of the terminal bronchioles, ''capillary 
bronchitis/' and by extension involves the air-vesicles and acquires the 
character of a true pneumonia. Bronchopneumonia is, as a -rule, 
bilateral, and only exceptionally involves a single lobe of one lung. 
The disease usually produces inflammation of the pleura. The affected 
lung acquires increased weight and the regions most involved acquire a 
firmer consistence and a deeper red or a grayer color than normal, de- 
pending on the stage of the inflammation, which at the outset occasions 
intense congestion without much leucocytic exudation. On section, 
the affected portions typically appear mottled, owing to the contrast 
apparent between the masses of solid and aerated lobules. 

Microscopic examination reveals an inflammation of the bronchioles 
and of the walls of the air-vesicles immediately surrounding. There 
is not only an exudate in the air-vesicles, but also an interstitial exu- 
date. In the bronchopneumonic exudate, the cells are more predomi- 
nantly mononuclear, and the amount of fibrin is less than in the exu- 
date of lobar pneumonia. The lesions are distributed throughout the 
lungs in patches, but show a tendency to become conglomerate as the 
disease advances. When the inflammation subsides the exudate is 
removed, as at the termination of lobar pneumonia by mechanical 
processes and by the agency of autolysis. The interstitial infiltration 
characteristic of bronchopneumonia is responsible for the occurrence 
of its more important sequelae, none of which commonly follow lobar 
pneumonia. These are chronic bronchitis, spasmodic asthma, emphy- 
sema, and chronic interstitial pneumonia. Pleurisy, when it occurs in 
children, irrespective of the character of complicating pneumonia, is of 
a productive type. 

Physical Signs. — Auscultation — The signs elicited by auscultation 
depend upon the stage of the disease and the degree of lung involvement. 

The Respiratory Murmur. — The respiratory murmur may be weak- 
ened over certain areas, or it may be scarcely discernible. Usually an 
involved area will be found to shade off gradually to the normal. 
There may be several of these areas. 

Rales.' — Areas of localized fine mucous rales are very suggestive of 
bronchopneumonia. The fine crepitant rale is often heard over the 
consolidated area. In cases in which there is a considerable distribu- 
tion of the pneumonic process there will be a wide distribution of rales, 
with sibilant and fine, moist, mucous rales predominating. The rales 



334 THE PRACTICE OF PEDIATRICS 

are only evenly distributed in cases of the acute congestive type. In 
these cases they are heard both on inspiration and on expiration, and 
are of a very fine, crepitant quality. 

Percussion. — In the very acute cases in which the engorgement 
interferes with the entrance of air into -the lungs extra resonance or 
tympanitic dulness may be found. In other cases the percussion-note 
serves as an indication of the degree and extent of lung involvement. 
The signs vary from normal to those of complete dulness. 

Palpation. — Whatever may be elicited by palpation is better dem- 
onstrated by auscultation and percussion. 

Symptoms. — The symptoms are most variable, depending upon the 
age of the patient, the severity of the infection, the extent of lung in- 
volved, and the associated illness and complications. 

In nearly all cases in which the process in the lungs is active there 
are three symptoms which rarely fail to be present: accelerated respira- 
tion, fever, and cough. The symptoms are only exceptionally urgent 
at the onset. Usually there is bronchitis for a few days, without high 
fever or rapidity of the respiration. Then, apparently on the eve of 
improvement, the temperature ranges higher, the respirations per min- 
ute increase, and the child shows prostration. 

Examination of the lungs at this time may reveal localized fine rales, 
usually posterior, in one or both lungs. As the urgency of the symp- 
toms increases the temperature ranges from 101° to 104°F., subject to 
considerable variations, and reaches the normal by lysis. 

The respiration is from 40 to 60. The pulse-rate is rarely under 
140. The usual range is from 140 to 160. Upon the appearance of 
these symptoms the chest signs become more marked. Localized 
areas of fine rales appear in different portions. There are also areas in 
which the respiratory murmur is very weak. Consolidation usually 
develops sufficient to produce bronchophony and bronchial breathing. 

Duration. — The duration of a case of this type in the event of 
recovery is rarely less than three weeks. Often a much longer time 
elapses before the chest will be free. In the fatal cases there is an 
increase in the volume of lung involved, shown by the physical signs. 
The heart action becomes feeble, and death takes place from exhaustion 
or supervening complication. 

Special Types of Bronchopneumonia. — In the description of a dis- 
ease with as wide possibilities as bronchopneumonia, a large number 
of types could be laid down which would add confusion to the subject. 
As in most diseases due to infections, death may take place very early 
or the infection may be so mild as to pass unrecognized. When we 
take into consideration the age of the patient, the varieties of micro- 
organisms that may be operative, and the amount of lung tissue that 
may be involved, we can readily appreciate that the disease is subject 
to many and varied manifestations. Among these possibilities there 
is one feature that should be emphasized. Consolidation of the lung: 
is not necessary for a right diagnosis of pneumonia. Elevation of the 
temperature, respiration over 40, dilatation of the alae nasi, and coughy 



BRONCHOPNEUMONIA (CATARRHAL PNEUMONIA) 



335 



together with mucous rales, usually definitely locahzed, are sufficient 
for a diagnosis of bronchopneumonia. 

Cases of the More Active Type. — Bronchopneumonia may be so 
severe as to be fatal in a few hours. At the New York Infant Asylum 
I saw several such cases which later came to autopsy. The condition 
is usually diagnosed as acute capillary bronchitis. In such patients 
the onset is sudden, with high fever, 103° to 106°r., rapid, labored 
respiration, 60 to 80, rapid pulse, 160 to 180, and cyanosis. There is 
marked prostration from the onset. The child is toxic and rapidly 
becomes unconscious. Auscultation shows a very marked increase in 
respiratory murmur and a few fine rales. The patients present 
evidence of a sudden invasion of pneumococci of a virulent type. 



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Fig. 42. — Temperature chart. Bronchopneumonia. 

Doubtless cases of this type are never correctly diagnosed. In two 
such cases seen by me a positive diagnosis could not have been made 
but for the autopsy. On account of the urgency of the symptoms and 
the cerebral manifestations of stupor and sometimes convulsions, the 
cases are looked upon as those of cerebrospinal meningitis, malignant 
scarlet fever, suppressed measles, or acute toxemia from intestinal 
sources. 

Postmortem examination shows an intense pulmonary congestion. 
A free incision in the lung removed immediately after death will be fol- 
lowed by a profuse flow of dark blood. Excepting the congestion and 
the presence of the pneumococcus, there are few findings to indicate the 
nature of the disease, the process having been too active and too 
rapidly fatal for the development of the lesions. 

Several years ago I was called to perform an autopsy on a six-year- 
old boy who had died after a two days' illness, the nature of which 



336 THE PRACTICE OF PEDIATRICS 

could not be agreed upon by the medical attendants, none of whom had 
suspected pneumonia. The autopsy findings were those of an acute 
pneumonia with intense pulmonary engorgement and with right heart 
dilatation, which corresponded to the clinical history. Cases of this 
nature represent the extreme possibilities of pneumococcus infection. 

There are other cases in which the symptoms are urgent but less 
pronounced. The onset is sudden, with high fever, 103° to 105°F. 
The respiration is rapid, 40 to 60, rarely there is a convulsion." Vomit- 
ing is usually present as an early symptom and occurs but once. 
Except in the nature of the onset, the course in these cases does not 
vary materially from the usual type first described. The temperature 
range, physical signs, duration and prognosis are much the same as in 
the cases of gradual onset. 

Bronchopneumonia Following Other Diseases, — When broncho- 
pneumonia follows pertussis, influenza, measles, or diphtheria, it 
shows no variations from its usual course, but finds a lessened resist- 
ance because of what has gone before. The prognosis is therefore 
correspondingly less favorable, the disease being particularly fatal with 
or after pertussis, measles, and diphtheria. 

Complications.^Among the complications, otitis is probably the 
most frequent. Empyema occurs in a small proportion of the cases. 
The same is true of pericarditis, meningitis, arthritis and nephritis. 
Emphysema is always present to a slight degree, and except in rare 
instances is demonstrable in autopsies on children dying with broncho- 
pneumonia. If the illness has been a long one, with considerable lung 
involvement, the emphysema may be very extensive. 

Differential Diagnosis. — Bronchopneumonia is to be differentiated 
from acute bronchitis and lobar pneumonia. When the respiration 
is persistently above 40 per minute and the temperature persistently 
above 102°F., uncomplicated bronchitis does not exist, and pneumonic 
involvement of the lung is highly probable. 

If there is an associated bronchial spasm increasing the respiration, 
a differential diagnosis is more difficult and sometimes impossible, as 
pneumonia may exist with a low temperature range. 

In lobar pneumonia the well-defined consolidated area in the lung, 
the absence of bronchial catarrh, and the usually persistent high 
temperature (see Fig. 41) are sufficient to establish the type of the 
infection. 

The age of the patient may be of assistance. Lobar pneumonia is 
uncommon under two years of age, and the great majority of the cases 
of bronchopneumonia occur before this period. 

Prognosis. — Bronchopneumonia is a disease of high mortality. In 
children's hospitals and institutions a considerable portion of the total 
mortality is due to bronchopneumonia. It is safe to say that from 25 
to 50 per cent, of the hospital cases are fatal. This, of course, includes 
all cases of bronchopneumonia, those complicating whooping-cough, 
measles, scarlet fever, and diphtheria, as well as the terminal cases that 
occur late with many other ailments of infants and children. The 



BRONCHOPNEUMONIA (CATARRHAL PNEUMONIA) 337 

age and previous condition of the patient have a decided influence 
upon the mortality. The younger and feebler the patient, the less is 
the chance for recovery. 

Rachitis, malnutrition, and marasmus are indirectly accountable 
for many deaths. 

Treatment. — Every child at the commencement of an illness has a 
definite resistance to disease. In catarrhal pneumonia, for the reasons 
just given, it must be our effort to preserve every strength unit which 
the child possesses. An immense amount of vitality in sick children is 
wasted because of irritability, restlessness, and loss of sleep. One of 
the first duties in a given case is not to give this or that drug or use this 
or that local application, but to make the child comfortable — to put 
him in the best position to withstand disease. We must establish and 
maintain a high degree of resistance, and must establish a sick-room 
regime which will make this possible. 

The Sick-room. — The value of a constant supply of fresh air is too 
little appreciated. In every case there should be a direct communica- 
tion between the sick-room and the open air throughout the attack. 
Various means of ventilation have been devised, of which the window- 
board (p. 138) is the most effective, as it separates the sash and allows 
the free entrance of a current of air which is directed upward. If 
plenty of fresh air at a proper temperature were available during the 
early part of the illness, there would be much less use for tanks of 
oxygen later. 

An absolute necessity in a sick-room is a thermometer. In 
pneumonia cases it should never register above 70°F. There is a 
marked tendency to coddle, to wrap, and to overclothe these patients. 
The patient requires, even during the winter, absolutely nothing more 
than a medium-weight flannel shirt, a band, if one is ordinarily worn, 
and the usual night-dress. Some years ago I discarded the oiled-silk 
jacket. It is cumbersome, it is impossible to keep clean, and it over- 
heats the patient. An infant with catarrhal pneumonia, heavily clad, 
in an unventilated, overheated room, and in close contact with an 
adult body, is tremendously handicapped. There is but one place for 
a sick infant, and that is in his own roomy crib. 

Diet. — In every illness with fever the digestive capacity is consider- 
ably reduced. If the usual milk diet is continued, we are very liable 
to have a gastro-enteric infection added, often as a serious complication, 
to the existing disease. For the breast-fed child a drink of water 
should be ordered before the nursings and between them. The nurs- 
ing hours should be the same as in health, but the time allowed for each 
nursing should be reduced from one-third to one-half. For the bottle- 
fed the milk strength should be reduced from one-third to one-half by 
dilution with water, the quantity remaining the same. Children from 
two to four years of age should be restricted to a diet of diluted milk, 
gruels, and broths. 

Bowels. — Normal bowel function is more necessary for the sick than 
for the well. There should be at least one stool in twenty-four hours. 
22 



338 THE PRACTICE OF PEDIATRICS 

General Treatment. — Having placed the child under the best dietetic 
and hygienic conditions, we are in a position to use medication to a 
much better advantage. But in its use, and in performing the various 
offices for the patient, it must be our effort to disturb him as little as 
possible. In our anxiety to do, we are very liable to overdo, with dis- 
astrous results. If a well child were given syrup expectorants, stimu- 
lants, baths, and local applications, something being done for him every 
hour or two in the twenty-four, he would have to be strong to withstand 
the treatment. We should treat our ill with still greater consideration. 
The intervals between which the child is to be disturbed at night should 
be made as long as possible by giving food, medicine, and local treat- 
ment at one time. When possible, I always endeavor to make the 
interval at least three hours. 

Steam Inhalations. — Among the distinctly remedial measures, aside 
from those administered internally, steam inhalations with creosote 
deserve an important place. The patient is placed in the crib, which 
is covered and draped with sheets so as to make a fairly tight inclosed 
space. The apparatus necessary is an ordinary croup kettle. Ten 
drops of creosote are added to one quart of water and placed 
in the kettle. The nozzle of the kettle is introduced between 
the sheets at a safe distance from the child's face and hands, the steam- 
ing being carried on for thirty minutes every three hours. The sheets 
should be parted slightly about every ten minutes, to allow a renewal 
of the air. The inhalations are to be given whether the patient is 
asleep or awake. As he improves, they may be given less frequently 
until normal respirations and the chest signs tell us this treatment is no 
longer required. 

Counter irritants. — The application of counterirritants to the skin 
over the thorax is, to my mind, of great service in cases in which there 
is much bronchial catarrh. This includes, of course, most cases. In 
order that a counterirritant may be of service, a distinct red blush must 
be produced on the skin. Turpentine diluted with oil, — one-third 
turpentine and two-thirds oil, — when briskly rubbed on the parts for a 
few minutes, produces a fairly satisfactory counterirritation. The old- 
fashioned home-made mustard plaster has also served me well. Writ- 
ten directions should always be given for the preparation of the plaster, 
and the boundaries of the area of the skin to be covered should be out- 
lined with a pencil on the skin's surface. If the nurse or mother is told 
merely to put a mustard plaster on the chest, a plaster the size of a 
man's hand will usually be placed somewhere between the umbilicus 
and the chin. For the first two or three applications one part of mus- 
tard to two parts of flour is used. This is moistened with warm water 
and made of the consistence of a rather thin paste, which is then spread 
upon cheese-cloth, old musHn, or linen, cut to the desired size. The 
plaster is readily held in position by a bandage or any thin material 
extending around the chest. When the skin is well reddened — usually 
within from five to fifteen minutes, — the plaster is removed and vaselin 
or sweet oil is applied. I never use a plaster oftener than once in six 



BRONCHOPNEUMONIA (CATARRHAL PNEUMONIA) 339 

hours, and then only in the severest cases. Ordinarily, two or three 
applications in twenty-four hours are sufficient. If the plasters are 
continued for several days, in order to avoid blistering it will be neces- 
sary to make them much weaker after a day or two— one part of mus- 
tard to five or ten of flour. Counterirritation is particularly effective 
when used at the commencement of an attack. 

Mustard Baths, — In cases of sudden onset with high fever, rapid 
breathing, and cold extremities, a mustard bath — one tablespoonful 
of mustard to six gallons of water at 110°F. — will often furnish marked 
relief from the immediate symptoms. The duration of the bath should 
be from one to three minutes, and while in the bath the skin should be 
subjected to active manipulation by hand rubbing. Autopsies on such 
subjects show a general congestion of the internal organs, with intense 
congestion of the lungs. The bath may be repeated at six-hour inter- 
vals. This type of bronchopneumonia is usually very rapid in its 
development, the child being relieved or dead within thirty-six to 
forty-eight hours. By '^ relieved'' we do not mean that the child has 
recovered, but that the acute, urgent symptoms have subsided. In 
my opinion only these rapid cases should be considered primary. 

Drugs. — The internal medication is, to a large extent, symptomatic. 
In any disease a great deal of harm may be done to young children by 
the thoughtless use of drugs. In catarrhal pneumonia it is particularly 
necessary that, in our endeavors to assist the patient, we do nothing to 
harm him, for we are treating a disease in which his powers of resist- 
ance count for everything. In young children, even in health, the 
digestive functions are very easily disordered. In illness with fever, 
with the accompanying nervous exhaustion, the stomach is most easily 
disturbed, the child is not properly nourished, and his powers of resist- 
ance are markedly diminished. 

Expectorants must be given with care, and are better prescribed 
in the form of tablets or powders. The use of heavy syrups of wild 
cherry, tolu, etc., with large doses of the ammonium salts, only adds to 
the burden of the patient. For a child one year of age with catarrhal 
pneumonia, 3^oo grain of tartar emetic and 3^o grain of ipecac answer 
well as an expectorant. If the cough is very severe and persistent, }/i 
grain of Dover's powder in tablet form, with sugar-of-milk dissolved in 
at least two teaspoonfuls of water, may be given, preferably after feed- 
ing, not oftener than once in two hours. The ammonium salts so 
generally used in catarrhal pneumonia for routine treatment are badly 
borne by the stomach. Ammonium muriate is of some value during 
resolution, but to a child two years old it should not be given in larger 
doses than J^ grain well diluted, at two-hour intervals. Personally, 
however, I rarely use it. 

In the event of high fever and great restlessness, which are not 
affected by sponging, and where, for any reason, rational bathing is 
impossible, a combination of caffein, Dover's powder, and phenacetin 
may be used. For a child one year of age I would give 3^^ grain of 
caffein, H grain of Dover's powder, and 1^ grains of phenacetin at 



340 THE PRACTICE OF PEDIATRICS 

about four-hour intervals. In giving Dover's powder it is well to 
watch the bowels, as constipation often follows its use. 

Heart stimulants are usually necessary, and in their selection two 
points are to be considered — their effect on the heart and their effect 
on the stomach. But, first, what are the indications for the use 
of heart stimulants? Ordinarily, I think, they are used too early. 
A heart stimulant should never be given simply because a child has 
pneumonia or diphtheria or scarlet fever, but it should be given in 
pneumonia or diphtheria or scarlet fever as soon as the heart needs 
assistance. Briefly, there are two conditions to guide us — a very rapid 
pulse and a soft, not rapid, pulse, with a tendency to irregularity. In 
a general way, I believe that a heart which is beating at the rate of 150 
a minute during quiet or sleep, and which is not strengthened by spong- 
ing or packs, needs assistance. The drug which has served me best is 
tincture of strophanthus, which acts as a direct stimulant to the heart 
muscle. The pulse, by its use, is made stronger, fuller, and less rapid. 
When the heart's action shows a tendency to irregularity, with a soft, 
easily compressible pulse, then strychnin is the remedy. Caffein 
sodiosalicylate in 3'^-grain doses every two hours is also of much use in 
such a condition. For a child one year of age one drop of strophanthus 
in water may be given every three hours, or J:3oo grain of strychnin 
every three hours, to be increased to 3^^oo or even to J^oo grain every 
three hours for a few doses, if the case is carefully watched for symp- 
toms of strychnin poisoning. Strophanthus and strychnin possess 
advantages over all other stimulants in that they do their work and 
have no unpleasant effect on the stomach, as is the case with alcohol, 
digitalis, and the ammonium preparations. If the condition is very 
urgent, strophanthus and strychnin may be used in combination. I 
rarely employ digitalis because of its tendency to interfere with diges- 
tion. Alcohol in the form of whisky or brandy is very rarely of great 
service in catarrhal pneumonia. It may stimulate the heart, but its 
prolonged use greatly upsets the stomach. It should be withheld until 
late in the disease, when other means of stimulation fail. Then, given 
in large amounts, it may be the means of saving the patient. One- 
half dram of whisky or brandy, well diluted, may be given every hour 
or every two hours to a child one year of age. However, the cases of 
catarrhal pneumonia actually saved by the use of alcohol are few indeed. 
Nitroglycerin, 3^:300 grain every three hours for a child one year of age, 
is of service in cases where there is marked cyanosis with cold extremi- 
ties. Its use should be discontinued as soon as improvement in this 
respect is noticed. The one unpleasant feature that I have observed 
from its administration is its tendency to produce headache and 
marked restlessness. 

Hypodermic Medication.— In all urgent cases in which collapse is 
threatened, or when stomach medication does not give results desired, 
I employ the hypodermic, using the same dosage as given by the 
mouth. Camphor may be given in two-grain doses and repeated 
hourly if necessary. Digitalin, 3-^ 00 grain, may be given and repeated 



BRONCHOPNEUMONIA (CATARRHAL PNEUMONIA) 341 

in three or four hours. For urgent collapse, camphor and 1 : 1000 
solution of adrenalin, 3 to 5 minims, are our best stimulants. 

Baths. — A sponge-bath at 95°F. for cleansing purposes may be 
given daily. 

Pyrexia. — What is to be our guide in dealing with the pyrexia? 
At what degree of temperature are we to interfere? This depends to a 
great extent upon what is behind the fever and the effect of the fever 
upon the individual patient. If a child has a high fever and is more 
comfortable when it is reduced, if he will digest his food better and sleep 
better, our duty is to reduce temperature. Further, by reducing it 
we lessen the work of the heart, saving many beats per minute. Usu- 
sdly, when the rectal temperature has a tendency to run above 104°F., 
interference is of advantage, and the best means at our command is the 
use of local applications of water in the form of sponge-baths or packs. 
If the temperature is easily controlled, a sponge-bath will answer our 
purpose. Either salt or alcohol may be added to the water. Ordina- 
rily, two teaspoonfuls of salt to a quart of water, or one part alcohol to 
three parts water, is ample. Cold water thus used serves two pur- 
poses — it acts as a sedative and it reduces the fever. Cold sponging, 
while not as effectual as a bath or a pack, possesses the advantage of 
being applicable even in the hands of the most unskilled. For spong- 
ing, the child should be stripped and covered with a flannel blanket, 
the sponging being done under the blanket. In order not to antagon- 
ize or frighten him, it is best to begin with the water at 95°F. and gradu- 
alh^ to reduce the temperature to 70° or 75°F. by the addition of ice 
or cold water. The sponging may be continued from ten to twenty 
minutes, and should not be repeated at shorter intervals than ninety 
minutes. After the sponging is completed the skin should be rubbed 
briskly for a few minutes with a dry towel. If the temperature is not 
readily controlled in this way, it is best to use other means, as too 
frequent sponging exhausts the patient. As a means of controlling 
the temperature in children, the tub-bath has not been successful in 
my hands, for the reason that I have not been able by this means to 
control the fever. The exposure, the fright, and the necessary short- 
ness of the bath render it very unsatisfactory. 

By far the best means at our command for controlling a continued 
high fever is the cold pack (p. 777). Properly applied, it is without the 
slightest danger. A large bath-towel or an}^ thick absorbent material 
may be used, slits being cut in one end of the towel through which the 
arms may pass. The towel should be folded over the body, and should 
extend from the neck to the middle of the thighs, the arms and the legs 
from the knees down remaining free. A hot-water bag, carefully 
guarded, should be placed at the feet. The towel is moistened with 
water at 95°F. It is well to make the pack warm at first, so that the 
child will not be frightened, as shock will thus be avoided. I have 
known severe shock to occur when a child with a temperature of 105°F. 
was put suddenly into a pack at 70°F. In two or three minutes the 
towel is moistened with water at 85 °F., then at 80°F. When 80°F. is 



342 THE PRACTICE OF PEDIATRICS 

reached, it is best not to make the water any colder for half an hour, at 
which time the temperature of the patient is taken. If, in the begin- 
ning, it is 105°F. and at the expiration of the half-hour shows slight or 
no reduction, the temperature of the pack may be reduced to 70° or 
even to 60°F., by the addition of cold water or ice, without removing 
the child, who is turned from side to side so that all parts of the envelop- 
ing towel may be moistened with cool water. During the first hours 
in the pack the temperature should be taken every half-hour, and when 
it is reduced to 102°F., the child should be removed and wrapped in a 
warm blanket. In cases of sudden and persistent high fever the child 
may be kept in the pack continuously. We aim to keep the tempera- 
ture between 102.5° and 103.5°F. A fresh towel should be apphed 
every three hours. An ice-bag should be kept at the head, a hot-water 
bag at the feet, and the patient should be covered with a flannel blanket 
of medium weight. The degree of cold necessary to control the fever 
in a given case will soon be learned. I recently kept in a pack for 
seventy-two hours a four-year-old boy ill with lobar pneumonia. In 
this case a pack at 70°F. was necessary to keep the temperature at 
104°F. or slightly lower. 

Oxygen. — Oxygen is of immense service in very severe cases with 
much lung involvement. It may be given continuously for one or two 
minutes out of every seven or ten. As often given, for one or two 
minutes every half-hour, it is of little or no service. 

INTERSTITIAL PNEUMONIA, INCLUDING BRONCHIECTASIS 

Interstitial pneumonia occurs in two types of cases. After bron- 
chopneumonia the interstitial variety represents an unresolved pneu- 
monia, and usually means that the individual has had more than one 
attack. The great majority of such cases are seen in ill-conditioned 
infants in hospitals and institutional homes. Rarely is this type seen 
in older children. I have seen but six cases in children over four years 
of age. 

The second type represents the cases of unresolved pneumonia, 
usually lobar pneumonia, which have been complicated by empyema, 
and in which the empyema has not been recognized or has been im- 
properly treated. 

Pathology. — Chronic interstitial pneumonia is a productive inflam- 
mation characterized by thickening of the connective-tissue framework 
of the lung. This disease follows one or more attacks of broncho- 
pneumonia or may accompany a chronic empyema. The process may 
involve one or more lobes of the lung, or only a portion of one lobe. 
The involved lung is usually adherent to the chest-wall by very dense 
fibrous adhesions, and is smaller than normal, firm, and grayish in 
color. On section, the pleura and connective-tissue septa are found to 
be greatly thickened. The bronchi are often dilated, and may be the 
seat of purulent bronchitis. 

Microscopic examination shows that the interlobular septa, the 



INTERSTITIAL PNEUMONIA, INCLUDING BRONCHIECTASIS 343 

walls of the bronchi and blood-vessels, and the alveolar walls are thick- 
ened with connective tissue. As a consequence some alveoli may be 
compressed and empty. 

Comj>ensatcry emphysema is often present in a portion of the 
unaffected lung. 

Symptoms. — Not half the symptoms described by writers exist. 
The principal manifestation is afforded by the condition of the patient, 
who is anemic, emaciated, and fails to thrive, or improves but slowly 
even under the best surroundings. 

There may be cough and, rarely, fever. The respiration is acceler- 
ated upon exertion, but otherwise shows no change. If there is an 
associated bronchiectasis, in older patients, there will be mucopurulent 
or purulent expectoration. 

A boy who was under my care for several years expelled free ex- 
pectoration about once a day. There was an interstitial pneumonia 
involving the lower half of the right lung, which was the seat of one or 
more bronchiectatic cavities. The pus evidently collected periodically 
and filled the cavity, then irritation would be excited, producing cough 
and emptying of the cavity. 

Diagnosis. — There may be extensive retraction of the chest-wall 
or none at all, depending on the age of the patient; in infants under 
eighteen months there is rarely such retraction. 

Upon forced inspiration, as in crying, it will be noticed that the 
chest-wall over the involved lung area fails to take part in the normal 
respiratory excursion. In the cases of older children there are varying 
degrees of retraction, usually associated with spinal curvature. 

Auscultation. — The respiratory signs are subject to wide variations. 
Thus in one case there may be bronchial breathing over one diseased 
area and entire absence of the respiratory murmur over another area. 
Between these extremes in the same case there may be every variety 
of abnormal respiratory sounds. Over the uninvolved lung the respira- 
tory murmur undergoes pronounced exaggeration. If there is a con- 
siderable bronchiectasis, signs of a cavity will be indicated by amphoric 
breathing. 

Percussion. — Percussion invariably shows localized dulness over 
the diseased portion of the lung. One may find all shades of dulness 
to flatness. Over the free portion of the lung, hyperresonance will be 
found because of the emphysema, which is always present in slight or 
moderate degree. 

Differential Diagnosis. — The question that always arises in these 
cases relates to the possibility of tuberculosis. A considerable number, 
particularly of the young, do develop tuberculosis. An examination 
of the sputum and the von Pirquet tuberculosis test should invariably 
be made. In cases in young infants a positive von Pirquet reaction 
supplies reliable corroborative evidence. Repeated examination of 
the bronchial secretions (p. 362) will reveal the tubercle bacillus if it is 
present. In the cases of older children examination of the sputum 
quickly determines the diagnosis. 



344 THE PRACTICE OF PEDIATRICS 

Prognosis. — The prognosis in infants is very unfavorable. If 
tuberculosis does not develop, intercurrent diseases, such as the intes- 
tinal diseases of summer, whooping-cough, measles, or further acute 
pneumonia, will very likely terminate the case. Recovery is not im- 
possible, however, and I have known infants to make almost complete 
recoveries after the process had existed for months. In one case the 
child's chest did not begin to "clear" until after the third month. In 
recovery cases the interstitial change could not have been at all exten- 
sive. In older children, after the sixth year, recoveries as regards life 
are the rule. Whether the case follows a bronchopneumonia or a 
pneumonia with empyema, even with the best results, there will be left 
a more or less crippled lung, which does not necessarily compromise 
the later well-being of the patient. Such patients, however, are more 
hable to tuberculous infection, and this possibility is always to be taken 
into consideration in their management. 

Bronchiectasis. — Bronchiectasis is present in a considerable num- 
ber of these cases, both in the young and older children. It consists of 
dilatation of the bronchi, such dilatation being usually sacculated or 
cylindric in form. The lungs of a child eighteen months of age who 
died from bronchopneumonia of three months' duration, with termi- 
nal sepsis, presented several small cylindric dilatations. One of these, 
with a capacity of six drams, was found in the right lung. This case is 
similar to many seen at autopsy. In young infants bronchiectasis 
may be very difficult of demonstration. In the cases of older patients 
the expectoration of pus in a chronic pneumonia is very suggestive, 
and in such instances physical examination may reveal amphoric 
breathing and other signs of cavity. 

Dilatation of a bronchus may be cylindric, sacculated, or spindle- 
shaped. It is accompanied either by atrophy or by hypertrophy of the 
mucosa and of the entire bronchial wall. Dilated bronchi contain 
thick mucous or purulent secretion, often in very large amount. The 
secretion may be blood-stained, due to rupture of some of the very 
numerous blood-vessels in the hypertrophied mucosa. Pressure of the 
dilated bronchi often causes collapse of the pulmonary alveoli surround- 
ing them. The walls of neighboring bronchi may fuse, forming larger 
cavities. 

Treatment. — The treatment of interstitial pneumonia is not par- 
ticularly brilliant in results. There is always the hope that the inter- 
stitial process dependent on cicatricial change is not extensive, for this 
feature determines in no little degree the outcome of the case. When 
resolution takes place, it occurs always from the periphery toward the 
center of the diseased part. The involved area becomes smaller and 
smaller and disappears, or, more frequently, as the ultimate outcome, 
an area of weakly vesicular breathing remains to mark the site where 
the disease was most active. 

Little can be accomplished by the use of drugs except to improve 
the nutrition of the patient. Children with this unfortunate pulmo- 
nary disease should take up their permanent residence in a dry climate, 



PNEUMOTHORAX 345 

such as is furnished by Colorado or New Mexico. A visit of a few 
months or a year is of but little service. I have used the iodids and the 
bichlorid of mercury for months without any appreciable improvement 
in two of these patients who could not be removed from town. The 
citrate of iron and quinin, one grain in a dram of sherry wine, makes a 
good appetizer, and may be given in one-fourth glass of water after 
meals. Its use can with advantage be alternated with that of the 
syrup of the hypophosphites (Gardner), one to three drams being given 
daily in one-half glass of water after meals. Cod-liver oil may be used 
with advantage for ten days out of the month, but its continued use is 
contraindicated, as it is apt to interfere with digestion. 

In one of the cases above referred to the iron was given for ten days 
and the oil for ten days, after which the procedure was steadily repeated. 
The patient continued to look well, gained in weight, and remained 
under treatment until he took up an occupation and passed from ob- 
servation. The condition of the lung had remained unchanged, the 
only active manifestation of the disease being the expectoration of a 
considerable amount of non-tuberculous pus every morning on rising. 

Infants and children with bronchiectasis who cannot be removed 
to a favorable climate should have the advantages of outdoor life, and 
older children should have as much active exercise as is possible with- 
out fatigue. The diet and general management are the same as for 
pulmonary tuberculosis (p. 361). 

Gymnastic Therapeutics. — For the purpose of expansion of the lung 
with the hope of curing the chest deformity gymnastic exercises are of 
the greatest value. (See p. 803.) 

HYPOSTATIC PNEUMONIA 

Hypostatic pneumonia is a form of lobular pneumonia which de- 
velops in fatal cases in the most dependent portions of the lungs, these 
portions having become very hyperemic as the result of weakness of the 
heart and respiration in patients who are severely ill. 

The affected pulmonary tissue is dark red in color, very firm, and 
airless. On section, the cut surface is red and very moist, exuding 
blood freely. Microscopically, the capillaries and veins are distended 
with blood, and the alveoli are filled with red blood-cells, leukocytes, 
and desquamated epithelium. The bronchi are usually in good condi- 
tion. The extent of the consolidation varies. While it usually occu- 
pies only a superficial strip along the posterior border and base of the 
lungs, fully half of the lower lobes may be involved. 

PNEUMOTHORAX 

Air in the pleural cavity may be due to tuberculosis, or to trauma 
(usually through exploratory puncture), causing perforation of the 
lung. I have seen one case of this nature. Pneumothorax also may 
occur in empyema. By far the most frequent cause in children is the 



346 THE PRACTICE OF PEDIATRICS 

formation of a cavity in the course of tuberculosis, supplying a commu- 
nication between the bronchi and the pleural cavity. Artificial 
pneumothorax has been advocated as a means of treatment for 
tuberculosis. 

Symptoms. — In the tuberculous cases the symptoms comprise very 
sudden onset of urgent collapse, urgent dyspnea, cyanosis, and rapid, 
feeble pulse. In cases due to trauma the symptoms may be urgent or 
scarcely noticeable, depending upon the extent of the lesion. In the 
case referred to, which developed after exploratory puncture, only a 
moderate amount of air entered the pleural cavity and no inconven- 
ience was occasioned. 

Physical Signs. — The physical signs are determined largely by the 
amount of air entering the pleural cavity. They may include simply 
hyperresonance and absence of respiratory sounds. In cases of tuber- 
culous origin there is usually a sudden inrush of air, with resulting 
immobility of the affected side and enlargement of that side of the 
thorax. There is marked hyperresonance, and an absence of fremitus. 
In cases in which the amount of air is not excessive there will be tym- 
panitic dulness. 

Auscultation reveals very weak breath-sounds or entire absence of 
the same. The coin test is very diagnostic. A coin is placed on the 
chest, either anteriorly or posteriorly, and tapped with another coin 
by an assistant, while the ear of the examiner is placed on the opposite 
aspect of the same half of the chest. The sharp metallic sound con- 
veyed, in comparison with the absence of sound over the opposite lung, 
furnishes a demonstration to students that will never be forgotten. If 
there is fluid in the pleural cavity, splashing, metallic, tinkling sounds 
may be heard. 

Prognosis. — The prognosis depends upon the cause of the air in 
the pleural cavity. The tuberculous cases are rapidly fatal. After 
trauma the recovery depends upon the nature of the injury. In the 
case referred to as following exploratory puncture, the patient re- 
covered without treatment. 

Treatment. — In empyema the fluid should be removed by surgical 
procedures. In instances in which there is marked displacement of 
the heart and considerable intrathoracic pressure, tapping the chest 
with a needle, and allowing an escape of the air, may be of value. 

EMPHYSEMA 

Emphysema is a secondary disease. There are few autopsies on 
children dying from pulmonary disorders in which it is not found pres- 
ent in greater or less degree. It is always present in considerable 
degree in cases of interstitial pneumonia, and in this association the 
emphysema is compensatory in character. It is found with whooping- 
cough, bronchopneumonia, habitual spasmodic bronchitis, and true 
asthma. 

Pathology. — Emphysema is most frequently found in a pronounced 
degree in the upper lobes, especially at the anterior borders and the 



SUBCUTANEOUS EMPHYSEMA 347 

apices. The air-vesicles are persistently dilated, and on inspection, to 
the unaided eye, present a picture of innumerable pin-point air-bubbles. 
When the septa give way, the vesicles enlarge so that blebs of various 
size occur. The condition rarely becomes interlobular. 

Symptoms. — In many cases there is no special manifestation, and 
the fact that emphysema exists is discovered only at the autopsy. 
This is particularly apt to occur in compensating cases in which there 
is a good deal of lung involvement, as in interstitial pneumonia or in 
prolonged bronchopneumonia. 

When there has been repeated spasmodic bronchitis or true asthma, 
there is shortness of the breath, with rapid breathing, and the thoracic 
wall presents a fixed appearance, owing to the diminished or impercep- 
tible respiratory excursion. 

The so-called barrel-shaped chest is seen in children, but it is of com- 
paratively infrequent occurrence. The child usually has a dry cough, 
is incapable of the usual exertions of early life, and readily becomes 
cyanosed through air-hunger. 

Percussion. — There is increased resonance on percussion, general 
in distribution, but most marked over the upper lobes in front. When 
the emphysema is not excessive, tympanitic dulness may be elicited. 
The area of cardiac dulness may be much smaller than normal or en- 
tirely obliterated. 

Auscultation. — Upon auscultation the respiratory murmur is found 
to be feeble, and expiration is noticeably prolonged and longer than 
inspiration. Squeaking, small, dry rales are usually heard in children 
because of the almost invariable association of bronchitis. The rales 
are heard both on inspiration and on expiration. The respiratory 
sounds have been aptly described as wheezing in character. 

Prognosis. — The prognosis in general emphysema is unfavorable. 
The attacks of recurrent asthma or recurrent spasmodic bronchitis, 
which occasion the process, continue, and the condition becomes most 
pitiable. Dilatation of the right heart ultimately occurs. Cardiac 
failure and acute pulmonary processes are the usual terminal affections. 

Treatment. — The management is that of the associated disease. 

SUBCUTANEOUS EMPHYSEMA (EMPHYSEMA OF THE MEDIASTINUM) 

This is a rare condition in children. I have seen but a few cases. 
Before the use of intubation, when tracheotomy was in vogue, many 
more cases were seen than now. Other causes may be pertussis, tuber- 
culosis, or trauma to the lung. The first occurrence is in the mediasti- 
num, whence the emphysema extends to the subcutaneous tissues and 
is particularly apt to appear above the clavicles, where it produces a 
cushion-like effect. In one of my cases the emphysema extended from 
this point downward over the thorax, and upward, involving the entire 
neck. 

Prognosis. — Cases following operative procedures and trauma may 
recover. When the condition is a complication of pulmonary disease, 
the outlook is very unfavorable. 



348 THE PRACTICE OF PEDIATRICS 

PRIMARY PLEURISY 

Acute, primary pleurisy is a very rare condition in children. I have 
seen but five cases under nine years of age — one patient was eight; one, 
seven; one, four years of age; one, two and a half years; and one, only 
fifteen months old. 

Pathology. — In these cases there is inflammation of the pleura with 
exudate, but usually not sufficient inflammation to produce an appre- 
ciable exudate in the pleural cavity. 

Symptoms. — The onset of the disease is practically the same as in 
adults. There is localized pain — the so-called ^'stitch in the side;" the 
respiration is rapid — 40 to 60 to the minute — and shallow; the skin is 
dry and hot; the cough is teasing, and, on account of the pain which it 
causes, is partially suppressed by the patient. Fever is present, usu- 
ally ranging from 102° to 105°F. The pulse is rapid— 120 to 150 to the 
minute. In two of my cases the pleuritic inflammation was followed 
by effusion. The fluid in both cases was sterile. So far as we could 
learn, there was no associated rheumatism in any of the cases. 

Treatment. — The treatment which proved successful in the five 
cases was rest in bed. The patients were given a reduced diet of milk, 
broths, and gruel. The fever was not of a very persistent character and 
was readily controlled by sponge-baths (p. 780). A flaxseed and mus- 
tard poultice, — one part of mustard to nine parts of flaxseed, — appHed 
as hot as could be borne by the back of the nurse's hand, and changed 
every half-hour, gave much relief from the pain during the acute stage. 
After the first twenty-four hours, however, poultices are of little value. 
Strapping the affected side with strips of Z. O. plaster will give much 
comfort when the pain continues after the second day. Tincture of 
aconite in doses of one drop every hour was given to the older children 
until ten drops had been given. It produced a fairly free diaphoresis 
and made the patients more comfortable. A grain of calomel is 
divided doses was given early in the attack, ^{q grain being given every 
hour. The duration of the acute symptoms was ordinarily from twelve 
to twenty-four hours, the entire duration of the illness ranging from five 
days to one week. In the case of effusion in the youngest child, absorp- 
tion appeared to be stimulated by the introduction of the needle and the 
withdrawal of a small amount of fluid, the remainder quickly disappear- 
ing afterward. To relieve the cough, small doses of codein, }{o grain 
every two hours, were given the older children. 

Ultimate Results. — That these cases were not of tuberculous origin 
was proved, not only by the absence of the tubercle bacilli, but by the 
complete recovery and continued good health of each patient during 
the next few years. These cases antedated the von Pirquet test for 
tuberculosis. 

SECONDARY PLEURISY 

This form of pleurisy is of very frequent occurrence in the young. 
Etiology. — In by far the larger number of cases, pleurisy occurs as 
a complication of pneumonia. 



SECONDARY PLEURISY 349 

Tuberculosis is probably the next most frequent cause. 

Secondary pleurisy may occur with pericarditis; such an association 
however, is rare. 

Bacteriology. — Acute fibrinous (dry) pleurisy accompanying pneu- 
monia in children is caused by the identical bacterium found in the 
consolidated areas of lung tissue. This type of pleurisy is more com- 
mon with lobar pneumonia than with bronchopneumonia. 

In acute serous pleurisy accompanying pneumonia small numbers 
of pneumococci may be found in the fluid. Clear, serous, pleural 
fluid containing streptococci has been described. 

In the tuberculous cases the fluid contains the tubercle bacillus, 
demonstrable by staining methods or by intraperitoneal injection into 
guinea-pigs. On ordinary culture-media tuberculous serous fluids 
give no growth. Pleurisy with serous effusion may occur with acute 
rheumatism. The Poynton-Payne diplococcus of rheumatism has 
been found in the fluid of such cases. 

Pathology. — Following or coincident with pneumonia there may 
occur what is known as a dry pleurisy, or pleurisy with effusion. When 
dry pleurisy exists, the pleura loses its usual luster, and, early in the 
attack, is covered with a slight fibrinous exudate. Exudation may go 
no further than this, or it may become most extensive, resulting in a 
network of thick, fibrinous bands, in the meshes of which there is a 
thick, gelatinous mass composed largely of fibrin and pus-cells. 

Repeatedly at autopsy I have found the lung so thoroughly 
bound to the chest-wall that its removal without the aid of force was 
impossible. 

In pleurisy with effusion sl fluid composed either of pus or of serum 
will be found in the pleural cavity. I have never seen such a case of 
pleurisy secondary to pneumonia in which the effusion did not contain 
bacteria. The fluid upon withdrawal may appear clear, yet bacterio- 
logic examination -will show that it is not sterile. The evidence of 
bacteria in the fluid may be, and often is, the first manifestation of a 
purulent pleurisy or empyema. 

Pleurisy of tuberculous origin is usually of the dry type. Tubercles 
will be found on the pleura, and there is more or less exudation of 
fibrin. If the process is an old one, there is considerable thickening of 
the pleura, with very firm adhesions. If there is a fluid, it usually 
exists in small amount, — 1 to 4 ounces, — sacculated, and may be 
serous or purulent. 

Symptoms. — Secondary pleurisy rarely exhibits distinct symptoms 
of its own. The manifestations are a part of the disease which the 
pleurisy complicates. There may be localized pain, but this is rarely 
of an active type. A sensation of tightness or constriction is more com- 
mon. It is surprising how little discomfort is present in a vast major- 
ity of these cases. When fluid is formed, whether serum or pus, there 
are, again, no active symptoms unless the fluid is excessive, in which 
event there wiU be interference with respiration, and, if the process is 



350 THE PRACTICE OF PEDIATRICS 

on the left side, the heart will show the effects of the pressure by rapid- 
ity and perhaps irregularity. 

The influence that the pleurisy exerts upon the temperature is 
difficult to determine, as the process is secondary to diseases in which 
temperature is a prominent feature. If the exudation is purulent, the 
temperature may take on the characteristic morning drop and evening 
rise. This will be very apt to occur in case of purulent exudation fol- 
lowing pneumonia, which is discussed in the following chapter under 
Empyema. 

Diagnosis. — The diagnosis is dependent more upon the physical 
signs than upon the symptoms. 

Auscultation. — In the cases without fluid exudate auscultation 
will often show either fine friction rales, which may be heard only at 
the end of inspiration, or the dry-rubbing friction crepitus heard with 
both inspiration and expiration. In the presence of fluid there wiU be 
weakness of, or absence of, respiratory murmur over the area covered 
by the exuded fluid. Rales also will be absent. Over the uninvolved 
lung area there will be an exaggeration of the normal respiratory 
sounds. 

Percussion. — In dry pleurisy there is no perceptible dulness; the 
child may complain that the percussion is painful. With fluid there 
will be dulness or flatness, depending upon the amount of fluid present. 
A small amount usually gives circumscribed dulness; a large amount, 
extreme dulness or flatness. Over the uninvolved portion of the lung 
there will be hyperresonance. 

Exploratory Puncture. — Exploratory puncture not only definitely 
determines the presence of fluid, but also its nature. 

Treatment. — The treatment of dry secondary pleurisy is usually 
that of the disease which the pleurisy complicates. I have never 
known special medication to be of any practical value. Tonics and 
supportive measures generally are of service. Anything that will 
improve the condition of the patient should be brought into use. A 
change of residence from the city to the country for those who can 
afford it, or an outdoor life in the city for those who cannot avail them- 
selves of such a change, is always beneficial. Counterirritation to the 
chest with mustard or iodin will often give relief to the patient if there 
is pain, but otherwise this measure possesses no value. When there is 
a sense of ''tightness" and constriction of the chest which amounts to 
pain, mustard or iodin will relieve the discomfort. Painting the 
affected area with tincture of iodin every second or third night has, in 
a few cases, afforded some relief. The administration of iodids as 
an aid to absorption is of questionable value, and is very apt to 
disturb the digestion. The application of a mustard plaster (p. 
328) — one-third mustard and two-thirds flour — to the bare skin over 
the diseased area for ten or fifteen minutes, at intervals of six or eight 
hours, will add to the comfort of the patient. When, after recovery 
from the pneumonia or the empyema, adhesions persist, compelling 
restricted lung action, active exercise in the open air is to be en- 



EMPYEMA (pleurisy WITH PURULENT EFFUSION) 351 

couraged. For younger patients horseback-riding, the bicycle, and 
breathing exercises, with physical games which call for active interest 
and require deep breathing, do better than anything else (p. 803). 

Presence of Fluid. — If the exploratory puncture shows the presence 
of serum, the fluid is best left, with the hope that it will be absorbed, 
unless it is in sufficient amount to compromise the respiratory function 
and the action of the heart. In such an event, several ounces should be 
removed by aspiration. In many cases the fluid has rapidly disap- 
peared after one aspiration. The aspiration may be repeated if nec- 
essary. During this operation care should be exercised to observe 
absolute asepsis. I have known cases to become rapidly purulent 
after the insertion of a needle. There is always a question in such 
instances, how much infection has been carried in on the needle. 

Preparation of the Skin for an Aspiration.^The skin should be 
thoroughly scrubbed with green soap. This is to be followed by wash- 
ing with alcohol, and then with equal parts of alcohol and tincture of 
iodin. The hands should be cleaned, and the instrument used should 
be sterilized, as for a surgical operation. 

If the pleurisy is of tuberculous origin, no particular management 
is carried out other than that of the primary disease, except in the 
event of symptoms of pain. This is to be relieved, as already de- 
scribed, by the use of local applications of mustard and iodin, with per- 
haps the administration of a sedative, such as small doses of codein. 

Dry pleurisy associated with pericarditis does not call for treat- 
ment other than that of the pericarditis, excepting in instances which 
call for the relief of pain. 

EMPYEMA (PLEURISY WITH PURULENT EFFUSION) 

In empyema there is a collection of pus in the pleural cavity, re- 
sulting from inflammation of the pleura which has become infected 
with pathogenic organisms. 

Age. — A vast majority of the cases occur in infants and children 
under four years of age. My youngest patient was three weeks old, 
and this child recovered. Comparatively few cases develop after 
the tenth year. 

Etiology. — In 95 per cent, of my cases the disease has occurred with 
evident pneumonia. Empyema may follow suppurative processes 
in any part of the body, but such cases are extremely rare. 

Bacteriology.— The pneumococcus is found in pure culture in the 
pus in about 75 per cent, of all cases in children. The streptococcus 
is less commonly present, and the Staphylococcus aureus is very rarely 
found. B. influenzae has been found in pure culture in purulent 
pleural fluid after influenzal pneumonia, and B. typhosus may cause 
empyema during an attack of typhoid fever. In cases of empyema 
following inflammatory conditions in the abdomen (appendicitis or 
peritonitis) B. coli communis has been isolated. 

Purulent effusion accompanying pulmonary tuberculosis may con- 



352 THE PRACTICE OF PEDIATRICS 

tain the tubercle bacillus, but pyogenic cocci also are almost always 
present. 

Pathology. — A purulent pleural exudation may follow serous in- 
flammation of the pleura, or the process may be a purulent one from 
the outset. The pus may be thin or thick, yellowish or greenish in 
color, and it may contain large masses of fibrin. The quantity of puru- 
lent fluid may vary from a few ounces to 30 to 40 ounces or more in 
neglected cases. While the inflammation may involve the entire 
pleural surface of one lung, it is more often limited to the lower lobe 
and to the posterior portion. Both pleural cavities may be involved. 
The pulmonary and costal surfaces of the pleura are usually covered 
with a fibrinopurulent exudate, and adhesions between the pleural 
surfaces and between the pleura and pericardium are readily separated 
at this stage. The lung substance beneath the exudate is more or less 
compressed, according to the amount of pus present. In extreme 
cases the affected lung portion may be completely airless, bloodless, 
gray in color, smaller than normal, and flattened against the vertebral 
column. The heart may be pressed toward the healthy side. In less 
severe cases the lung may be congested, and still contain some air. 

Empyema may heal completely in the early stage. Very often, 
however, it tends toward a chronic course. The pus frequently be- 
comes very thick, the formation of granulation tissue, and later of 
fibrous connective tissue, causes irregular thickening of the pleura. 
Adhesions between the pleural surfaces may thus be so dense as to make 
separation impossible, and an encapsulated empyema may be formed 
by the shutting off of a smaller or larger amount of pus by adhesions. 
The connective-tissue formation may even extend into the lung sub- 
stance, resulting in interstitial pneumonia. 

In cases of empyema which come to autopsy early in the disease the 
pneumonia preceding the empyema may still be present. In later 
stages, however, only a complicating bronchopneumonia, acute or 
chronic, may be found in one or more of the lobes not involved by the 
empyema, or an interstitial pneumonia in that portion of the lung sub- 
stance beneath the thickened pleura. 

In untreated cases the pus may be evacuated through a bronchus, 
externally through the chest-wall, or into the peritoneal cavity. 

Symptoms. — The child has a catarrhal pneumonia or a broncho- 
pneumonia, running the usual course as to fever, respiration, pulse, and 
prostration. After a time varying from six to twelve days an improve- 
ment in the symptoms is noticed, the pulse and respiration become 
slower, and the child appears brighter. For twenty-four to forty- 
eight hours the temperature range is quite low. During the height of 
the pneumonia it has been perhaps 104°F. to 105°F. Now the tem- 
perature ranges from 100°F. to 102°F., at times dropping to 99°F. 
Soon it becomes noticeable that the temperature is higher in the even- 
ing than in the morning, although the evening temperature may not be 
above 102°F., or at most 103°F. The child coughs, the pulse is rapid, 
— 120 to 140, — and the respiration is accelerated to 40 or more. The 



EMPYEMA (pleurisy WITH PURULENT EFFUSION) 353 

appetite is poor. These or similar symptoms may continue for weeks 
if the condition is not recognized. 

Empyema After Lobar Pneumonia. — More cases of empyema follow 
lobar pneumonia than the catarrhal type. The following sympto- 
matology covers a majority of the cases: The crisis occurs, and the 
temperature falls to normal (see Fig. 43) and remains normal for 
a few days ; or perhaps there is the temporary postcritical rise the day 
following the crisis. In other respects conditions continue favorable 
for perhaps two, three, or rarely five days, when a slight evening rise 



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Fig. 43. — Temperature chart. Empyema following lobar pneumonia. 



in temperature occurs. The temperature is lower the next morn- 
ing, but perhaps not quite normal; the following evening it is higher 
than the preceding, and the next evening it is still higher. Such a 
temperature range following pneumonia is almost pathognomonic 
of empyema (Fig. 44). 

In some few cases the exudation of pus into the pleural cavity is not 
delayed until the temperature falls, but develops during the first few 
days of the pneumonia. With the formation of pus the respiration and 
pulse increase in frequency, the respiration ranging above 40, and the 
pulse from 140 to 180. It is a mistake, however, invariably to expect 
characteristic signs. The lungs and heart soon accommodate them- 
selves to the changed conditions. Repeatedly I have seen cases in 
which there was but sHght acceleration of the pulse and respiration. 
The evening temperature, however, is rarely less than 102°F. In addi- 
tion to the symptoms enumerated, these cases (particularly those that 
have continued for two weeks or longer) show a symptom-complex that 
may almost be said to be characteristic. The child is emaciated and 
23 



354 



THE PRACTICE OF PEDIATRICS 



the face wears an anxious expression. The skin is pale, of a yellowish 
tinge, and perspires readily. The mucous membrane and conjunctivae 
are pale. Slight exertion causes embarrassment of the respiration. 
The nostrils are distended; the respiration during rest is short, and in- 
creased from 10 to 20 per minute above the normal. The fingers may 
show signs of clubbing. 

Diagnosis. — Diagnosis is based upon physical examination of the 
chest and exploratory puncture. Weakness or absence of respiratory 
murmur and absence of rales, combined with the presence of dulness or 
flatness, are indications justifying an exploratory puncture. 



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Fig. 44. — Empyema following lobar pneumonia. Operation. Recovery case. 



When the disease is located on the left side, the displacement of the 
heart to the right, as indicated by the changed position of the apex-beat, 
is a very suggestive sign. Over the uninvolved portion of the chest, 
auscultation will show exaggerated respiratory murmur; and percus- 
sion, hyperresonance. 

Differential Diagnosis. — (Blood examination, p. 397). Empyema 
is to be differentiated from serous pleurisy, pleurisy with massive 
exudation of fibrin, unresolved pneumonia, pulmonary tuberculosis, 
malaria, and typhoid fever. 

Serous pleurisy and pleurisy with a thick, fibrinous exudate give 
signs identical with those of empyema. In many cases of fibrinous 
pleurisy with a considerable exudate, not a rale or friction-sound will be 
heard. Our only means of differentiating empyema from these proc- 
esses is in an exploratory puncture with a large needle. 

In unresolved pneumonia the respiratory sounds are heard with 
greater distinction. Rales, and often friction-sounds, are present. 



EMPYEMA (pleurisy WITH PURULENT EFFUSION) 355 

The dulness is distinctly localized, and there is rarely flatness unless 
there is associated with the pneumonia a thick pleuritic exudate. 

In tuberculosis of the lung of sufficient gravity to allow of confusion 
the presence of tubercle bacilli in smears from the expectoration or 
tracheal secretion (see p. 362) may determine the diagnosis. The von 
Pirquet test (p. 702) may be brought into use. Here also, however, 
the exploratory puncture is the best means of establishing the diagnosis. 

The difficulties in differentiating typhoid fever and malaria from 
empyema should be slight, in view of the marked dissimilarity in the 
disease conditions. Nevertheless, cases of empyema are not infre- 
quently treated for typhoid and malaria when pus is apparent in the 
pleural cavity. When the lungs are proved normal by competent 
physical examination, then the tests for malaria and typhoid in daily 
use may be instituted. 

Treatment. — When pus is located, operation and drainage are the 
only methods of treatment. Aspiration is never to be looked upon as 
a substitute for incision. 

In a recent case in a young child under two years of age an incision 
with local anesthesia — ethyl chlorid answers the purpose — is all that 
will be required. In the case of an older child, or in a prolonged case 
in a young child, a resection of the rib is to be advised as furnishing 
much freer drainage. Occasionally cases are seen among older chil- 
dren in which, on account of a very severe, persisting pneumonia, it will 
not be safe to use a general anesthetic. In such cases an incision may 
be made under cocain — a 4 per cent, solution being injected into the 
skin at the site of the proposed incision. Such an operation will relieve 
the immediate symptoms — the displacement of the heart and the 
difficult breathing. The resection of a rib may safely be undertaken 
after a week or two, when considerable improvement will have taken 
place in the general condition. As soon as the cavity is opened, 
two half-inch drainage-tubes, from two to four inches in length, 
joined with a large safety-pin, are inserted. Gauze is packed around 
the tubes and against the skin, and upon this the pin rests. Sterile 
gauze is placed over the end of the tubes as soon as possible after 
their introduction, in order to prevent too free escape of pus. When 
the pus is allowed gradually to escape, much less shock will be experi- 
enced. Over the gauze, two or three layers of absorbent cotton are 
placed, and over this the bandage. The dressing should be changed 
every day and the tubes shortened as the lung expands. This ex~ 
pansion will be indicated by the resulting outward displacement of 
the tubes. After the evacuation of the pus the pulse usually falls to 
normal or nearly normal, where it remains. Occasionally, however, 
cases are seen in which this expected result does not follow the 
operation. 

Illustrative Case. — In one of my cases the operation was followed by a free dis- 
charge of pus, but with no relief whatever to the symptoms. An examination of 
the chest revealed at the apex of the lung a pocket of pus which had become walled 
off by adhesions. The case was one of three months' duration when it came under 
my care. A second operation removed about six ounces of pus, but the child died 



356 THE PRACTICE OF PEDIATRICS 

from exhaustion about twenty-four hours afterward. Autopsy showed that the 
pleural cavity was divided into two distinct pus-sacs by a firm band of adhesions. 

Failure of the temperature to subside in my cases in which complica- 
tions could be excluded has been due to defective drainage. The tube 
may be too small or plugged, or the pus may become sacculated. Large 
fibrinous masses which the tube will not admit may undergo slow de- 
generation and absorption and continue the temperature. 

Illustrative Case. — In a case of empyema following a pneumonia of great severity 
in a girl of five years, on account of the reduced condition of the child an incision 
was made instead of a resection of the rib. The temperature fell to normal, and 
all the symptoms improved for a few days, when an evening rise to 101°F. and over 
was noted, which in two or three days reached 103°F. There was a discharge 
which saturated the dressings, although they were changed every three or four 
hours. Our inabihty to locate an independent pus-pocket, the continued fever, 
and a strong odor to the discharge suggested the probability of insufficient drainage. 
In spite of the fever, the child having gained considerably in strength, a second 
operation was decided upon to enlarge the wound. She was anesthetized, and 
two inches of rib were removed, whereupon quantities of necrotic fibrinous material 
were found in the pleural cavity. These were removed with the finger and dressing 
forceps; the temperature immediately fell to normal, and the child made a perfect 
recovery. Irrigation of the cavity had been of no avail. 

Ordinarily the tubes should not be removed until from four to six 
weeks after the operation. At least one tube should be kept in posi- 
tion until a free respiratory murmur is heard all over the affected side, 
up to the site of operation in the chest-wall. When the lung is fully 
expanded, the tubes will be forced out and found in the dressings. Irri- 
gation of the pleural cavity is not to be advised as a routine measure, 
and with sufficient drainage it will not be found necessary. The cases 
which require irrigation on account of continued fever and insuffi- 
cient discharge require a resection of the rib. Should a second opera- 
tion be refused, on account of the tender age or the general weakness 
of the patient, or be inadvisable on account of some complication, 
such as a pericarditis, a daily irrigation with a sterile normal salt 
solution may be undertaken. 

Deformity Following Untreated Cases. — In hospital and out-patient 
work, cases neglected for weeks, showing marked chest deformity and 
retraction, usually associated with spinal curvature, are among those 
treated. The pus has been partially absorbed and partially organized, 
leaving extensive adhesions which have bound the lung tightly to the 
chest- wall, preventing expansion, so that the bony wall has become dis- 
placed inward to meet the lung. For these unfortunate children surgi- 
cal measures furnish some relief, but the results in my cases have not 
been brillant. 

Treatment by Siphon Drainage. — The siphon drainage, often 
named after Bulan, but previously used by Playfair, has, during the 
past five years, been considerably modified and made more efficient 
by Kenyon, of New York. This method is particularly useful in treat- 
ing infants. For detailed description see ''Siphon Treatment of Em- 
pyema in Infants," by Holt: American Medicine, new Series, vol. 
viii, No. 6, pp. 381-389. " 



EMPYEMA (PLEUKISY WITH PURULENT EFFUSION) 357 

Procedure. — An ordinary aspirating needle attached to a short 
rubber tube (2 to 3 inches) which fits closely to a glass Luer syringe is 
introduced into the chest in the seventh or eighth space in the scapular 
line, and the presence or absence of pus ascertained. The introduction 
of the needle should take place just below the lower border of the rib, 




Fig. 45. — Tube with window, cuff, and tape; bottle with long and short glass 
tubes, half filled with salt solution; the long tube is always below the level of the 
fluid (Kenyon). 



in order to avoid the artery. The larger portion of the pus should be 
aspirated with the syringe, as this considerably simplifies the procedure 
thereafter. After completion of this step the rubber tube is clamped 
and the syringe removed. 

A bistoury is inserted into the pleural cavity along the needle ; this 
puncture wound is now enlarged between the needle and the rib below 



358 



THE PRACTICE OF PEDIATRICS 



it. The incision should be the size of the drainage-tube, and not as 
large as the cuff; in this manner the drainage-tube with cuff attachment 
will be found to fit most snugly. 

The apparatus consists of a bottle, and rubber drainage-tube, the 
former of about one pint capacity, and filled three-quarters full of 
warm saline. The vessel is equipped with a perforated rubber cork 
into which fit two glass tubes, one just through the cork and the other 
reaching almost to the bottom, and connecting by its outer end with 

the drainage-tube. The 
tube is made of stiff rub- 
ber, inside diameter being 
/-{g to 3^^ inch and the 
wall of about }{q inch 
thickness. A soft-rubber 
tube collapses too readily 
and will not do. A window 
is cut near the end of the 
tube, and a narrow piece 
of tubing, fully 3^ inch 
long and from ^{q to ^{q 
inch inside diameter, is 
stripped over the drainage- 
tube, leaving about 1 to 
IJ^ inches protruding — 
just sufficient to enter the 
pleural cavity and effect 
drainage. Over the drain- 
age-tube is threaded a 
piece of tape (button- 
holed) about }y'2 inch wide 
and 5 to 6 inches long. 
This is made to fit snugly 
over the cuff, and in this 
manner helps to retain the 
tube within the pleural 
cavity. 
The drainage-tube is inserted into the chest by means of an ordinary 
artery clamp. The tape is drawn tightly over the chest and made fast 
with adhesive strapping. The latter may be built ''up" around the 
tube, thus adding further protection against leakage, and, in addition, 
serving to anchor the tube within the chest. Some split gauze around 
the tube fastened with adhesive completes the dressing. In order to 
promote siphonage the bottle is raised above the patient and some of 
the saline is permitted to run into the chest, in this manner increasing 
the fluidity of its contents. Usually the expansile power of the lung is 
sufficient, with a little stripping of the tube, to effect immediate drainage. 
Occasionally it will be observed that very little or no pus drains during 
the first twenty-four hours or so, and that a great deal of air bubbles 




Fig. 46. — Dressing complete (Kenyon). 



EMPYEMA (pleurisy WITH PURULENT EFFUSION) 359 

into the bottle, along with some blood-stained fluid. In these cases 
it may safely be assumed that the lung itself has been punctured and 
the tube, in these instances, should be shortened. The infant may be 
placed in bed, propped in such a manner as to effect the best dramage. 

During the first day or two it is usually necessary to empty the 
bottle two or three times, and in order to do this the rubber tube is dis- 
connected from the bottle and the end covered with gauze and clamped. 
If the discharge is very thick, the chest may be irrigated in the manner 
described above. With effectual drainage the temperature usually 
drops within twenty-four hours provided an extension of the pneu- 
monic process is not present. A sudden rise is always suggestive of 
a plugging of the tube with fibrin clots, and should be investigated by 
removing the tube and inserting a fresh one. Sometimes a larger 
tube is necessary in order to effect better drainage. 

The average time for leaving the tube in the chest is from two to 
three weeks, although in protracted cases drainage is sometimes neces- 
sary for two months. With a normal temperature, general improve- 
ment in the child's condition, cessation of discharge, and absence of 
leukocytosis the tube may usually be safely removed. Rarely is it 
necessary to reinsert the tube. In cases coming to autopsy either 
through extension of the pneumonic process or from general sepsis, the 
drainage has, without exception, been complete. 

The advantages claimed for this method may be summarized as 
follows : 

1. Simplicity and facility of the operation. 

2. Freedom from shock. 

3. Absence of pneumothorax. 

4. Single dressings which do not require frequent changings, and 
thereby lessen the danger of a mixed infection. 

5. Shortened convalescence. 

6. Efficiency of the drainage. 

Double Empyema. — But two cases coming under my observation 
have had both pleural sacs involved. In such cases both sides should 
not be opened at the same time, on account of the danger of collapse of 
the lungs. There are usually adhesions present sufficiently strong to 
prevent this, but we have no means of knowing this beforehand. In 
both of my cases the left pleural cavity was opened first, in order to 
relieve the pressure upon the heart and the great vessels. 

Illustrative Cases. — In one case a considerable quantity of pus was removed from 
the right side by aspiration at the time of the operation on the left side. The right 
side was operated upon four days later, by which time sufl5cient adhesions had 
formed to prevent collapse of the lungs. The patient, a boy of two years, made 
an excellent recovery. 

The second patient was one year of age. Pus had been present in both sides for 
a considerable time. The left side was opened first. The sac on the right side was 
smaller than that on the left, and was operated on by incision three days later. 
The child was very much reduced by the protracted illness. In spite of the free 
daily irrigation of both cavities, the typical temperature persisted until death, 
probably on account of the very extensive suppurating surfaces. The child died 
from exhaustion twelve days after the second operation. 



360 THE PRACTICE OF PEDIATRICS 

Empyema Necessitatis. — Spontaneous rupture of the pleural sac 
may occur in cases of empyema of considerable duration which are not 
properly diagnosed or not operated upon if diagnosed. Cases of this 
nature have been reported in which the pus ruptured into the esopha- 
gus, into the bronchi, or through the diaphragm into the peritoneal 
cavity. 

Illustrative Cases. — In two of the cases seen by me spontaneous rupture oc- 
curred. In the first, pus ruptured into the bronchi. The patient was a well- 
nourished boy three years of age. The pus was sacculated over the anterior 
portion of the left lung. The parents, not particularly intelligent people, objected 
to the operation, and while it was under consideration by them, two or three days 
after the diagnosis was made, the pus ruptured into the bronchi and was discharged 
from the mouth in large quantities during a coughing paroxysm. The child made 
an uninterrupted recovery. 

The other patient, a boy of two years, came under observation for a soft 
fluctuating swelling, the size of a small orange, on the right side, immediately below 
the nipple. Exploration with a hypodermic needle showed pus. An incision 
was made and about three ounces of pus discharged. When the sac was emptied, 
it was found to communicate with the right pleural cavity by an opening between 
the seventh and eighth ribs. The wound was dressed and the child recovered 
without further complications. 

PULMONARY GANGRENE 

Pulmonary gangrene is a very rare complication of pneumonia. 
I have seen but three cases, all of which developed during the course of 
a bronchopneumonia. The gangrene is supposed to be due to an em- 
bolism of some branch of the pulmonary artery, or to a septic throm- 
bosis. The odor of the breath is most characteristically offensive, 
and is in itself diagnostic. As a complication of pneumonia pulmonary 
gangrene is invariably fatal. 

Except for the odor of the breath, there are no significant symptoms 
which may not exist with the usual attack of bronchopneumonia. 



PULMONARY ABSCESS 

Pulmonary abscess is a very unusual complication of pneumonia. 
At any rate, comparatively few cases are diagnosed, because of the 
occurrence of the abscess with empyema or because symptoms re- 
sembHng empyema are present. The abscess is usually discovered 
during exploration for pus in the pleural cavity. 

Illustrative Case. — The only case of this nature that has occurred under my 
personal observation was that of a patient two years of age. The case was one of 
the first in my private practice. The child had a pneumonia of the right upper 
lobe, which failed to resolve after abatement of the urgent symptoms. The 
temperature continued at 101° to 102°F., and there was a distressing cough. 
The family were becoming restless, and my patient was about to pass into other 
hands, when, at the family's suggestion, I changed the medication and gave a 
mixture containing full doses of syrup of ipecac and ammonium chlorid. This was 
given repeatedly without dilution, against instructions, and produced violent 
emesis. During a vomiting seizure the child brought up a considerable amount of 
pus, after which the recovery was prompt. Evidently the straining had produced 
a rupture of a pulmonary abscess into one of the larger bronchi. 



PULMONARY TUBERCULOSIS 361 



PULMONARY TUBERCULOSIS 



Infection of the lungs with the tubercle bacillus furnishes the chief 
manifestation of tuberculosis in the human. The lungs are the most 
active seat of the process in at least 90 per cent, of the cases. 

Pathology. — In the most acute form of pulmonary tuberculosis 
the lungs contain gray, translucent tubercles in varying numbers. 
These may be only few in number, or both lungs may be very closely 
studded with them. The lesions may also be present on both surfaces 
of the pleura. Acute bronchopneumonia, with or without fibrinous 
pleurisy, may exist. In a late stage the tubercles undergo cheesy 
degeneration and are yeUow in color. The coalescence of neighboring 
tubercles may give rise to cheesy masses, which eventually undergo 
softening. The tubercles are more often peribronchial than perivas- 
cular in distribution. Owing to the more direct course of the right 
main bronchus, the right lung is often involved before the left. 

Cheesy degeneration of an area of pneumonic exudate may occur, 
and the resulting cheesy pneumonia frequently leads to softening and 
cavity-formation. These cavities may occur in any part of the lung, 
but are most common in the right middle and upper lobes, and usually 
communicate with a bronchus. Their walls are irregular and grayish in 
color; blood-vessels may be seen crossing them; and their contents are 
cheesy or necrotic material. 

The connective tissue of the lung is increased in cases of pulmonary 
tuberculosis which have undergone repeated attacks of pneumonia, 
or which follow empyema of long standing. In such cases the pleura 
also is thickened and may be covered with a cheesy exudate. 

Phthisis as it is seen in the lungs of adult subjects is not met with 
in children under eight or ten years of age. 

The bronchial lymph-nodes in cases of pulmonary tuberculosis are 
involved in the tuberculous inflammation in about 97 per cent, of the 
cases. This is contrary to A. Ghon who holds that the tubercle bacil- 
lus does not pass through the lungs without leaving a lesion there. The 
nodes are enlarged, and on section show all stages of tuberculosis, from 
discrete tubercles with small cheesy centers to cheesy degeneration of 
the entire node. Softening or suppuration is very common, while 
calcareous degeneration of a tuberculous focus in a lymph-node is 
infrequently seen in infants, but is less rare in children over two years 
of age. The bronchial and mediastinal lymph-nodes may be so much 
enlarged as to afford dulness on percussion and occasion respiratory 
difficulty from pressure. 

Symptoms. — In infants and very young children there is no char- 
acteristic symptomatology. This seems strange in a disease of such 
gravity. Even in the miliary type, where we have been taught to ex- 
pect high temperature, rapid respiration, and other severe toxic symp- 
toms, such symptoms do not always exist. The signs correspond to 
those of bronchopneumonia — fever, 101° to 104°F., rapidity of respira- 
tion, cough, and the chest signs peculiar to catarrhal pneumonia. 



362 THE PRACTICE OF PEDIATRICS 

There may be only cough and the evidence of a generaHzed bronchitis. 
The temperature range is not characteristic, and may not differ from 
that of bronchopneumonia. 

A suspicious symptom in an infant is steady emaciation out of pro- 
portion to the other positive evidences of disease. The child takes 
food well, sleeps well, and is comfortable. There may be a slight eleva- 
tion of the temperature or no elevation throughout the illness — in fact, 
I have known the temperature to run a subnormal course. 

In older children after the third year the disease manifests itself 
by more distinct signs, such as emaciation, loss of appetite, fatigue on 
slight exertion, and perhaps night-sweats. There is, moreover, a trou- 
blesome dry cough with little expectoration. Elevation of tempera- 
ture in older children is an invariable symptom. It may not be high, 
however, perhaps not above 102°F. in the evening. The child com- 
plains of chilliness and soon shows signs of anemia. Pain is unusual, 
and hemoptysis rarely occurs. 

In the miliary type in older children the symptoms are also active, 
particularly the temperature, which will range very high, — 103° to 
105°F., — or it may be low in the morning and high at night. The res- 
piration and the pulse are rapid. Cough is not a prominent symptom. 
There is rapid loss in weight. 

It will be observed that the symptoms may aid us but little. The 
diagnosis is to be made with laboratory aid. 

Diagnosis. — For the positive diagnosis of tuberculosis in children 
the presence of the tubercle bacilli must be proved. The examination 
of the lungs, except by showing the existence of a cavity, aids us but 
little, for, in the miliary type, there may be tuberculosis without chest 
signs. The various lung changes which may be evident on examina- 
tion in no way differ from those which may be found in acute or chronic 
bronchopneumonia. Accompanying tuberculosis, moreover, there 
may be a bronchial catarrh, which in no way differs in its manifesta- 
tions from that of simple generalized bronchitis. 

A positive von Pirquet test (p. 702) is strong corroborative evidence 
of tuberculosis in young infants. The presence of fine crepitant rales 
localized over the right middle lobe (front) means a localized tuber- 
culous process, the bacilli being conveyed by the lymphatic channels 
extending from the bronchial glands to the spaces between the lobes, 
middle and upper. I have seen the value of this sign proved in a large 
number of cases. In the case of older children the test, while positive, 
may be misleading, as the tuberculosis may be a latent process or entirely 
healed, and have no bearing on the immediate illness. 

After the fourth or fifth year the diagnosis is seldom beset with 
the difficulties that surround the infant. At the later period of life 
localized signs of bronchitis, or partial or complete consolidation with 
dulness, may be manifest. Further, children at this age expectorate, 
so that collection of the sputum is easily accomplished. 

Methods of Obtaining Sputum. — In deafing with infants who do not 
expectorate, a satisfactory method of obtaining the bronchial secretion 



PULMONARY TUBETICULOSIS . 363 

is to pass a sterile catheter in the child's larynx. This excites coughing, 
the secretion is brought up through the larynx and adheres to the tube. 

Another method which may be used consists in irritating the 
pharynx with a small piece of sterile gauze grasped in an artery clamp. 
As a result of the coughing thus induced the secretion from the trachea 
will be deposited on the gauze. Several tests may be necessary before 
the bacilli are discovered. 

Bacilli in the Stool. — To search for bacilli in the stool is not a very 
satisfactory procedure, and is not necessary, in view of the success 
attending the above methods of securing material for examination. In 
suspicious cases in which the sputum examination fails to reveal the 
bacillus the stools should be examined. 

Prognosis. — The prognosis for infants is very unfavorable. Never- 
theless in infants, healed tubercular foci are occasionally found at 
autopsy. A child eighteen months of age who died of diphtheria had 
a large encysted calcareous tubercular nodule in the left lung, 1 inch by 
1}^ inches in size. Likewise the bronchial glands may show evidences 
of previous disease. In view of the large percentage (over 60 per 
cent.) of positive reactions to the von Pirquet skin test in children 
past ten years of age, it would seem that there are many more cured 
cases in children than has heretofore been appreciated. After the 
fifth year, if the case is seen reasonably early, if the child has a fair 
resistance, and if the management can be suitably carried out, the 
prognosis is very good indeed. I have had a recovery from pulmonary 
tuberculosis in a child of four years. The prognosis is further favorable 
if the infection is primary. If there is a lighting up of an old tubercu- 
lar lesion in the bronchial glands or elsewhere, the prognosis is much 
less favorable. I have repeatedly had recoveries in New York City in 
primary cases in children who could not be sent away. 

Associated Lesions. — The invasion of the tubercle bacillus usually 
means the involvement of more than one organ or portion of the body. 

The Liver. — -An autopsy in a case of pulmonary tuberculosis will 
very frequently show, in addition to the evidences of the disease in the 
lung and pleura, that the liver is involved to the extent of showing a 
generous distribution of tubercle bacilli in its surface and in the liver 
substance. 

The Spleen. — It is rare, in making a postmortem examination in 
pulmonary tuberculosis, not to find the spleen the seat of the disease. 
Both the surface and the splenic tissue may be filled with tubercular 
deposits. 

The Heart. — Tuberculosis of the heart muscles is very unusual. 
A few cases have been reported. The pericardium is occasionally the 
seat of a few tubercles. They are usually found when there is an ex- 
tensive general tuberculosis. Their presence does not constitute tu- 
berculosis of the pericardium. 

Stomach. — Tuberculosis of the stomach is of very rare occur- 
rence. Hale reports having seen but five cases in his large autopsy 
experience. 



364 THE PRACTICE OF PEDIATRICS 

Intestines, — Infection of the intestinal mucosa without further ab- 
dominal involvement is occasionally seen at autopsy. 

The Kidney, — The kidney is very frequently the seat of tuberculo- 
sis. About 25 per cent, of my cases have shown such lesions. They 
are usually of the miliary type, scattered over the surface, with a few in 
the kidney substance. 

Tuberculosis of the larynx in children is of very unusual occurrence. 
Demme reported a case in a child four and one-half years old (Kophk). 

The pancreas, thymus gland, and peritoneum are rarely at autopsy 
found to be the seat of a few miliary tubercles. 

Tuberculosis of the cervical lymph-glands, hrain, mesenteric glands, 
peritoneum, and abdomen will be discussed in separate chapters. 

Treatment. — Climate. — For those who are so situated financially as 
to have the advantages of an equable climate, a change of residence 
or sanitarium treatment should be provided. A dry climate of equable 
temperature that will allow the tuberculous child to spend the greatest 
number of hours in the open air is best. The climate of southern New 
Mexico and Arizona is exceptional for these cases. I have had children 
do well in the Adirondacks and in Sullivan County, New York, but the 
severity of the winter makes these localities less desirable. 

Diet. — Equally important, if not more so than climate, is the nutri- 
tion of the patient. This must be raised to the highest possible stand- 
ard, but there should be no overfeeding, such procedure being of no 
value in any disease in the young. My patients have improved most 
on a high-proteid diet of milk, meat, and eggs, and a high proteid cereal, 
such as oatmeal, and the legumes — dried peas, beans, and lentils, which 
are given in the form of a puree. I have found it advisable not to in- 
sist that a definite amount of food be given in twenty-four hours. The 
mother or nurse is to be told, however, that these foods, prepared in 
different ways so that the child will not tire of them, are to form a con- 
siderable part of the diet. Green vegetables, fruits, and plain desserts 
should be given for the sake of variety and to stimulate the appetite. 
When three meals a day are given, with, perhaps, a glass of milk in the 
middle of the afternoon, I have been able to maintain better nutrition 
than with more frequent feedings. Forced feeding in children often 
defeats its own purpose by producing disgust for or intolerance of food. 
The child should be fed on nutritious food, for which an appetite must 
be developed ; for, inasmuch as recovery is dependent largely upon nu- 
trition, the question of appetite and food capacity is of paramount 
importance. Candy, sweet crackers, and other harmful articles 
should not be allowed. In order to satisfy the candy craving, a small 
quantity of sweet chocolate may be given after the noonday meal. 
The best appetizers that we can furnish the child are reasonable exer- 
cise, entertainment and play that do not fatigue, and fresh air in 
abundance. Upon our ability to meet these requirements, depends, to 
a large degree, the outcome of the case. 

The majority of the children with pulmonary tuberculosis cannot 
be sent to sanitariums or to health resorts. The patients must be 



PULMONARY TUBERCULOSIS 365 

treated in their homes. This I have done successfully in New York 
City even among the tenement population. The basic principles of 
management comprise a properly directed life, good food, and fresh 
air. These are the weapons for fighting the enemy, regardless of 
whether the residence is among the rich or poor, in town or in country. 
It is, however, among the tenement population that we experience the 
greatest difficulty. To tell these people how the child is to be fed is not 
enough. The feeding as directed entails considerable expense, which 
the parents may not be able to meet. If after personal investigation, 
which should be made in every case, it is demonstrated that proper 
nutrition or suitable clothing is impossible, I explain the situation to 
some charitably inclined person of means, and have yet to know of an 
instance in which clothing and a small but sufficient weekly food-allow- 
ance were not forthcoming. To the best of my knowledge the child 
himself has always had the benefit of the charity, and I have investi- 
gated such cases closely. An allowance of 25 cents a day for fresh 
meat and milk has often furnished what was required to bring the case 
to a favorable termination. The uselessness of much of our medical 
advice to the poor would, on slight reflection or a little investigation, be 
apparent. Directions are too often given for the care of the sick which 
are absolutely impossible of fulfilment. 

Hygiene. — In addition to the diet above outhned, the advantages 
of an outdoor life, and the means by which fresh air may be obtained 
all the year round, should be fully explained. Any simple direction as 
to what may appear to be a radical procedure is rarely carried out with- 
out a rational explanation of its necessity. During the daytime the 
child should be kept outdoors. Close, tightly sealed sleeping apart- 
ments at night, however, will undo the good of the outdoor life during 
the day. The mother should be told to have the child sleep alone in 
the largest room of the apartment, and always in a room in which the 
windows are opened. This is usually possible. A sponge-bath or tub- 
bath should be given at bedtime, followed by brisk rubbing with a 
towel. If there is much emaciation, an olive-oil or goose-oil inunction 
should follow the salt bath. 

Sometimes these directions are followed implicitly; at other times 
they are forgotten. It is astonishing, however, what rapid improve- 
ment will follow when a tuberculous child of tenements is given the 
benefit of fresh air, day and night, with suitable food and cleanliness, 
even though the conditions are those of New York City. Among the 
more fortunate classes the same method of treatment, of course, with 
a more satisfactory application, is to be carried out. Among the well- 
to-do, however, we see fewer cases. 

Tonics. — The usefulness of drugs depends to a large degree upon 
an increase of food capacity which their use may cause. Any of the 
prescriptions written below may be used alternately with cod-liver oil 
and malt, each being given for five days. For a child from seven to 
twelve years of age the following are useful restoratives and appetizers: 



366 THE PRACTICE OF PEDIATRICS 

I^ Tincturse nucis vomicae gtt. Ixxi] 

Saccharini gr. iss 

Aquae q. s. ad giv 

M. Sig. — One teaspoonful every two hours. (Six doses daily.) 

I^ Ferri et quininae citratis gr. xxiv 

Vini xerici giv 

M. Sig. — One teaspoonful in water three times a day after meals. 

I^ Tincturae nucis vomicae gtt. Ixiv 

Extract! ferri pomati gr- vj 

Quininae bisulphatis 5j 

M. ft. capsulae no. xxx. 

Sig. — One after each meal. 

If night-sweats are present, from J'^qo to J-f eo grain of atropin at 
bedtime will often furnish relief. 

Care of the Sputum. — Various devices for collecting the sputum may 
be obtained in the shops. A cheap and effective method is the use of 
a Japanese handkerchief, which, when used, is- at once placed in a 
paper bag, the bag and its contents being burned at the close of the 
day. The dangers of infecting others should be fully explained to those 
in charge of the patient, kissing and fondling being forbidden. 

HELIOTHERAPY 

Heliotherapy or the treatment of bodily ills by exposure to the 
sun's rays has been utilized for curative purposes many centuries. In 
the Swiss Alps, RoUier and Bernhard were the first to take up helio- 
therapy in a scientific manner for the definite end of curing tubercu- 
losis. The method is very simple and consists in exposing the body 
to the direct rays of the sun for a given time. 

Most satisfactory results are reported by the above authors, par- 
ticularly in cases of surgical or bone tuberculosis. This method of 
treatment of tuberculosis has been carried on by Dr. Gerald Webb of 
Colorado Springs and the procedure is described as follows: Children 
can be exposed naked at an altitude of 4000 to 5000 feet when snow is 
on the ground because the temperature in the sun may be as high as 
90°F. or even 120°F. Patients arriving at this altitude are first al- 
lowed to become acclimated by rest indoors for a few days. Then 
they are placed on verandas with a white garment covering the body. 

Exposures to the sunlight are made very cautiously and gradually, 
fixed rules being followed no matter what part of the body may be 
effected with tuberculosis. On the first day, the feet are exposed three 
or four times at hourly intervals, for five minutes each time. 

On the second day, the bare legs, to the knees are exposed in a 
similar manner, and the feet are exposed three times for ten minutes 
eacho On the third day, these exposures are increased by five minutes, 
three times daily, and on the fourth day, the thighs are included. On 
the fifth day the abdomen and chest respectively are exposed. The 
pulse and temperature variations are used in guiding the treatment, 
and, in certain individuals, variations in the sun treatment are made. 



HELIOTHEKAPY 367 

By this method in summer or winter patients can remain from four 
to six hours bathing in the sun. 

Naturally other surgical methods are not neglected. Sphnts, 
braces, and the hke are employed, when necessary to limit motion in 
diseased joints. The appliances are made as light and as open as 
possible. Open wounds when not being sunned, are dressed with gauze 
soaked in alcohol. Such ''open" cases are found more refractory to 
the treatment than ''closed" cases. 

Certain blood changes have been noted, such as an increase in the 
number of the red blood corpuscles. Some observers, too, have 
claimed that the lymphocyte blood cells — known to be antagonistic to 
the tubercle bacillus — are increased by heliotherapy. We have not 
been able to confirm this in our work. 

V We have carried out this method of treatment for three years at 
Colorado Springs, but, while finding it to be of much benefit to our 
patients, with either bone, joint or glandular tuberculosis (surgical 
tuberculosis) as well as to those patients with pulmonary tuberculosis, 
we are not yet able to share the same high degree of optimism for the 
method which is held by RoUier. 

We feel it wise to warn patients against the careless employment 
of sun baths without proper medical control as harm can be done by 
them. The head should be protected, especially at first, by a light 
hat, and in the case of adults, Rollier sometimes advises the covering 
of the heart with a wet compress. 

My own limited observations of the sun treatment for tuberculosis 
have not been such as to warrant any great enthusiasm for this method 
of treatment. 



IX. DISEASES OF THE HEART 
DIAGNOSIS IN DISEASES OF THE HEART 

Auscultation. — In the diagnosis of the different cardiac lesions in 
children auscultation is by far the most useful means at our command. 
For adults the physician employs auscultation, either with the naked 
ear or with the stethoscope, at the following chest areas: 
The aortic area. 
The pulmonary area. 
The tricuspid area. 
The mitral area. 

In children tricuspid disease is of most infrequent occurrence. 
The pulmonary valves are involved only in congenital heart disease. 
In the routine examination for heart lesions in children the findings 
are simplified by the fact that aortic and mitral valve lesions are those 
encountered in an immense majority of the cases. 

Owing to the difference in the position of the heart of the child as 
compared with that of the adult, the various sound areas also differ, 
and they vary at the different periods of childhood in accordance with 
the changing position of the heart. 

Before the sixth year the mitral area corresponds with the apex- 
beat at a point in the nipple-line, or not more than 3^ inch without 
the nipple-line, in the fourth interspace. 

The aortic area is slightly to the right of the sternum in older chil- 
dren; in the very young, over the sternum or at its immediate right 
border, at the level of the second or third interspace, varying with the 
age of the child. 

The pulmonic area is on the same plane at the left border of the 
sternum. 

At the end of the sternum, slightly to the left, is the tricuspid area. 

It is by no means claimed that sound areas indicate the position 
of the valves, but we know, from combined clinical and autopsy find- 
ings in children, that murmurs indicating lesions of the respective 
valves are best heard at these areas. 

The Normal Sounds. — Hhe normal heart-sounds are not easily 
described. The normal cardiac cycle is made up of the^rs^ and second 
heart-sounds. Listening at the apex or slightly above, one hears at the 
time of the impulse the low-pitched, dull first sound, followed by the 
so-called second sound, which is short and higher pitched, and is sup- 
posed to be due to closure of the semilunar valves. 

There is much divergence of opinion as to the cause of the first 
sound. Most diagnosticians believe that it is due to the contraction 
of the heart muscles, associated with the sudden closure of the mitral 
valves. 

368 



DIAGNOSIS IN DISEASES OF THE HEART 369 

The heart-sounds vary considerably, depending upon the age of the 
patient; thus, in the infant both sounds are short and high pitched, 
and the muscle sounds which appear later in life, while present, are 
not prominent. 

There is rarely difficulty in differentiating the two sounds in the 
young. The second sound is heard loudest over the base of the heart 
at points corresponding more or less closely to the pulmonic and aortic 
areas. In the event of difficulty in differentiation, the first sound 
should be sought at the apex. On gradually moving the stethoscope 
upward, the first sound will gradually become fainter and as the base 
of the heart is approached the second sound will be heard much more 
distinctly and loudest in the areas referred to. 

The points of maximum intensity and areas of transmission of 
heart-sounds in children can not be arbitrarily laid down. In a gen- 
eral way the landmarks can be indicated, and in most instances will 
stand. 

In diagnosing cardiac disease in children we have to consider the 
age of the patient with particular reference to the size and position 
of the heart, whether the chest-wall is thin and muscular, or fat, and 
whether the child is crying or quiet. All cardiac sounds in the young 
are proportionately much louder than in adults. In delicate children 
the sounds vary greatly from those heard in the strong and robust. A 
first sound, characterized by a muffling or absence of clearness, is very 
frequently heard in delicate children. After an illness in a strong 
child this peculiar quality is very apparent, and is without doubt due 
to muscular insufficiency induced by degenerative changes which in 
most cases are temporary in character. 

The changed first sound is often interpreted and treated as an evi- 
dence of endocarditis. In heart failure in serious diseases, the muscle 
element of the first sound gradually disappears so that this sound be- 
comes short and snappy in quality, due to a degeneration of the heart 
muscle. The weak muscle sound tends to exaggerate the sound pro- 
duced by the valve closure. 

The second sound is caused by the closure of the semilunar valves, 
and as there are two sets of these valves, the aortic and pulmonary, 
the aortic second sound (in older children) is heard in the aortic area 
and the pulmonic second sound in the pulmonary area. 

In babies and very young children a differentiation of the aortic 
and pulmonic second sounds is unquestionably difficult. (Imagina- 
tion, however, carries many diagnosticians over obstacles.) The sec- 
ond sound is always accentuated in conditions in which the cardiac 
vigor is temporarily or permanently impaired, as in myocarditis with 
hypertrophy and dilatation of the left ventricle. 

Inspection. — Inspection alone is of little value in cardiac examina- 
tion. One learns nothing by inspection that may not be discovered 
through palpation, percussion, and auscultation. In acute cardiac 
disease in which there is often a decided overaction of the heart, a 
decided undulating movement of the entire left chest anteriorly will 
24 



370 THE PRACTICE OF PEDIATRICS 

be observed. This usually occurs when there is much dilatation or 
hypertrophy of the left ventricle. 

Inspection may reveal a retraction of the chest-wall at the apex 
between the fourth and fifth interspaces. This closing-in is due to 
adhesions (the result of a former pericarditis) between the heart, the 
pericardium, and the chest-wall. 

Palpation. — Palpation is useful in determining the position of the 
apex-beat, in judging of the force of the cardiac impulse, and in the 
detection of a thrill. The pericardial friction-rub and the heart 
rhythm may likewise be determined in this way. 

Percussion. — For this examination, I prefer the upright position. 
Percussion is chiefly of value in determining the size of the heart. 
Hypertrophy or dilatation of both the right and left heart may be 
fairly accurately determined. This method is also of value in deter- 
mining the amount of fluid in the pericardial sac. 

The normal right limit of absolute dulness for the heart may be 
taken as the left sternal border. The midsternal line supplies the 
boundary for relative dulness. The left limit of dulness corresponds 
to a perpendicular line drawn slightly without the apex-beat. 

The area of dulness will vary considerably in health. The younger 
the child, the further to the left will be located the border of cardiac 
dulness. This limit is best determined by percussing from a point in 
the anterior axillary line toward the right, in the fourth interspace. 

HEART MURMURS 

There are two gross divisions of heart murmurs : Organic or valvular, 
inorganic or functional (non-valvular) . 

Organic murmurs are the result of a change in the heart structure 
due to a congenital malformation or to deformities resulting from dis- 
eased processes which produce a thickening, contraction, shortening, 
or narrowing of the valves involved. 

An enlargement of the orifice (e. g., the mitral or aortic orifice) may 
also cause a murmur due to the resulting incomplete closure of the 
valves. 

Regurgitant Murmur. — When the valves fail to close, a murmur is 
caused by the regurgitation of the blood back through the opening. 
If the valves are roughened, the intensity of the murmur is the greater. 

Stenotic Murmur. — When the blood is impeded in its passage 
through the heart as a result of a narrowing of the opening or roughen- 
ing of the valves, a murmur of stenosis is the outcome. 

Organic heart murmurs are classified as follows, depending upon 
the time of their occurrence in the cardiac cycle: 
Systolic. 
Diastolic. 
Presystolic. 

From the association of the murmur with one or another of the 
different phases of the cardiac cycle we determine the location and 
nature of the lesion at hand. 



HEART MURMURS 371 

Location of Lesions. — In examination of the heart in order to 
locate a lesion by the murmur we must determine when it occurs in 
the cardiac cycle, its point of maximum intensity, and its area of 
diffusion. 

Acquired Lesions. — In children acquired valvular lesions will almost 
invariably be found to involve the left heart, the mitral valves being 
by far the most liable to disease. 

Mitral insufficiency takes first place in the order of frequency of 
valvular lesions. Mitral stenosis is evidently present in about 10 per 
cent, of the cases of insufiiciency. Lesions of the aortic valves are 
fortunately much rarer. The ratio of mitral to aortic disease is about 
15 to 1. 

Table Demonstrating Location and Character of Lesions Based Upon the 
Adventitious Heart-sounds or Murmurs 

Systolic Diastolic Preststolxc 

Mitral regurgitation. Aortic regurgitation. Mitral stenosis. 

Tricuspid regurgitation. Pulmonary regurgitation. Pulmonary stenosis. 
Pulmonary stenosis. 
Aortic stenosis. 

Pulmonary stenosis occurs only as the result of congenital lesions, 
and tricuspid lesions in children are only observed very late in severe 
cardiac disease, as a result or accompaniment of right heart failure. 
In the absence of these etiologic conditions a systolic murmur in a 
child must therefore be attributed to mitral regurgitation of aortic 
stenosis. Moreover, for the reasons explained, a diastolic murmur 
means aortic regurgitation, and a presystolic murmur, mitral stenosis. 

Acquired lesions in children will, therefore, permit of the following 
grouping. 

Systolic Diastolic Presystolic 

Mitral regurgitation. Aortic regurgitation. Mitral stenosis. 

Aortic stenosis. 

Keeping the time of the murmur in mind, we thus have a means 
of readily locating the lesions. 

Mitral regurgitation is due to shortening or adhesions of the mitral 
valves, sufficient to prevent proper closure of the leaflets. The valvu- 
lar defects are the result of a previous acute or chronic endocarditis. 
The murmur of mitral regurgitation is heard loudest in the apex region, 
over the so-called mitral area. In children, because of their thin chest- 
walls, this murmur has a wide transmission. The particular line of 
transmission is upward and to the left toward the axilla, and to the 
back, the sound being loudest at the angle of the scapula and between 
the scapula and the vertebrae. 

Mitral stenosis (producing a presystolic murmur) is due to a narrow- 
ing or partial permanent closure of the mitral orifice as the result of 
adhesions which bind the valves together, and produce, in some in- 
stances, the so-called funnel or button-hole opening. The murmur is 
heard loudest slightly above and to the right of the apex-beat. In 



372 THE PRACTICE OF PEDIATRICS 

point of time it precedes the systolic or first sound of the heart. Not 
infrequently the murmur merges into that produced by the mitral re- 
gurgitation, completely replacing the first sound of the heart. The 
area of diffusion is quite circumscribed. 

Mitral lesions which have existed for some time always give rise to 
compensatory hypertrophy, with corresponding displacement of the 
apex-beat to the left. This may readily be determined by palpation 
and percussion, showing the degree of cardiac enlargement. 

The Thrill. — As a result of the contracted orifice or the roughened 
valve surf aces, vibrations are produced in the blood-stream, which, when 
transmitted to the chest surface, produce a corresponding peculiar 
effect upon the palpating finger or hand of the examiner. This sign is 
known as a thrill. 

Aortic stenosis produces a systolic murmur which is heard loudest 
over the sternum and the second left costal interspace; not over the 
second right interspace or to the right of the sternum, as in the case of 
adults. The murmur, which is usually harsh and grating in character, 
is widely transmitted in a lateral direction and also into the carotids of 
the neck. Autopsy usually shows the existence of adhesions between 
the semilunar valves. 

In comparatively few cases a thrill maybe felt over the upper portion 
of the chest and the carotids. In a girl patient eight years of age 
there is a most exceptional thrill over the dilated arch of the aorta and 
the carotids. 

In aortic regurgitation the murmur is diastolic in time, and is heard 
not to the right of the sternum, but sharply against the left border, or 
over the extreme left of the sternum, on a level with the fourth costal 
cartilage. This murmur is usually associated with the obstructive 
murmur, and is due to a failure of the deformed valves to close. The 
area of diffusion is wide. There is always displacement of the apex- 
beat to the left. It is the condition of aortic regurgitation, preemi- 
nently, that causes visible pulsation of the carotids. In the child al- 
ready referred to, the throbbing was so pronounced that not only was 
the head and body shaken, but the mother, who slept with the patient, 
was kept awake by the vibration of the bed. 

Functional Murmurs. — Functional murmurs are most frequently 
encountered between the third and twelfth years. The functional 
murmur in infants or very young children will almost always be asso- 
ciated with anemia. This is not invariably the case, however, but a 
non-organic murmur at this age may be the result of a very severe 
illness or whooping cough, — causing a temporary dilatation. 

The functional murmur is systolic in time, and is heard loudest at 
or slightly above the apex, with a uniform, circumscribed area of diffu- 
sion which extends for only a few inches in any direction. In character 
the murmur is soft and blowing. It is not heard at the back. There 
is no associated hypertrophy or dilatation of the heart or evidence of 
any stasis or dropsy. There is no accentuation of the second sound. 
The functional murmur is not at all unusual in rapidly growing chil- 



HEART MURMURS 373 

dren of both sexes. The presence of a functional diastolic murmur in 
children is practically unknown. 

Venous Murmurs. — In anemia the normal venous murmur heard 
over the great vessels above the clavicle and posterior to the sterno- 
cleido-mastoid muscle is intensified and exceeds its normal physiologic 
Hmits. The murmur is constant, although it may be accentuated 
when the patient stands with head inclined to the opposite side. The 
venous murmur is to be distinguished from the arterial murmur by 
the fact that the former is continuous and not synchronous with the 
heart-beat. 

Etiology. — Anemia probably constitutes the most frequent cause, 
yet functional murmurs are heard in apparently normal children, 
existing for a period of years and then disappearing. A temporary 
murmur will often be heard in boys after violent exercises or games of 
competition in which a great deal of physical work is involved. In 
girls the murmur may also result from excessive bicycle-riding or pro- 
longed rope-jumping. In the spring of the year, after hard work at a 
school, many girls, under careful examination, will show a slight systolic 
murmur. In my opinion many of these cases are due to a dilatation 
of the left heart, producing a wider auriculoventricular orifice than 
the valves can completely close, with the result that there is a moderate 
amount of leakage. This, in time, is corrected as the heart muscle 
regains its normal condition. 

Differential Diagnosis. — The chief point of aid in differentiating all 
murmurs, whether functional, acquired, or congenital, is the fact that 
in congenital and acquired heart disease there is a distinct lesion, and 
the murmur, as can be readily understood, is, therefore, constant. 
When, however, the murmur is due to causes related to muscular action 
or blood conditions, variations in posture or changes in the heart 
action, dependent upon work, will produce either a modification of the 
murmur or its complete disappearance. Even during a single ex- 
amination a murmur of this nature may not always be the same. 

Illustrative Case. — A boy patient, aged six years, has a soft, blowing systolic 
murmur, which presents varying degrees of intensity, depending upon whether he is 
lying down or sitting up or whether he is quiet or exercising. I have known this 
boy since birth. The murmur appeared when he was two years old. He is, and 
always has been, the picture of health. The murmur is gradually becoming less 
each year and when he is ten years old will probably cease to exist. An older sister 
gave evidence of exactly the same condition, the murmur in her case disappearing 
at about the ninth or tenth year. The murmurs in these children were not anemic 
or cardiorespiratory. 

Cardiorespiratory Murmur. — This murmur deserves particular men- 
tion for the reason that it has a distinct entity. It may be heard in 
those cases in which the margin of the lung covers the heart. The mur- 
mur is usually systolic. It is heard best when the patient is standing 
and leaning forward, and at the end of inspiration is usually loudest. 
This murmur has no clinical signifiance, and is of interest only because 
it may be confused with other murmurs, functional or organic. 



374 THE PRACTICE OF PEDIATRICS 

Murmur During Development. — As already noted, a functional mur- 
mur is not at all unusual in rapidly growing children. 

After Acute Illness. — Inasmuch as the functional murmur which 
occasionally occurs with, and disappears after, an acute illness is in all 
respects similar to those that exist for several years and are later out- 
grown, it may be fair to assume that, in both instances, the same cause 
is operative, and that this factor, in all probability, is a moderate re- 
gurgitation, due perhaps to a dilatation of the mitral orilBce preventing 
proper closure of the valves, a condition temporary in both types of 
cases, but in the one of longer duration than in the other. 

Treatment. — The functional murmur requires no treatment. But 
the condition causing the murmur may require attention, and upon this 
conclusion the treatment must rest. 

PERICARDITIS 

Pericarditis is an inflammation of the pericardium. No period of 
life appears to be exempt. My youngest patient was six months of age. 
The disease occurs most frequently between the third and the twelfth 
years. Cases have been reported by different authors as occurring in 
fetal life. Pericarditis is the result of an infection and occurs practi- 
cally always as a secondary disease either in association with rheuma- 
tism or as a result of the invasion of pathogenic bacteria carried through 
the blood-stream or by the lymph from other portions of the body. 

Bacteriology. — The bacterium most often found in the sero- 
fibrinous or purulent exudate is the pneumococcus, a fact which is 
explained by the frequency of pulmonary lesions as the primary source 
of the infection in these cases — 70 per cent, to 90 per cent. The 
streptococcus or the staphylococcus aureus may be present; and 
very rarely B. influenzae or the gonococcus has been found in the course 
of septicemia due to these bacteria. The tubercle bacillus, as the cause 
of fibrinous or purulent pericarditis in children, is almost unknown. 
Tuberculosis is more apt to involve the external surface of the sac, 
owing to possible extension of tuberculosis of the lung. 

Poynton has found the diplococcus of rheumatism in the plastic 
exudate of pericarditis complicating rheumatism. 

Pathology. — Pericarditis possesses as wide possibilities as pleuritis, 
and the pathologic processes are quite similar. Thus, there may be 
only simple dryness of the lining of the pericardial sac, or a com- 
plete filling of the sac with serous or purulent fluid. Over the heart 
and the enveloping membrane only thin layers of fibrin may form; or 
the heart and pericardium may become firmly bound together by layers 
and bands of fibrinous exudate. Autopsies on purulent cases often 
show the heart wrapped in the meshy fibrinous exudate to such a de- 
gree that the muscle surface cannot be seen, while the inner surface of 
the pericardium is lined with a granular exudate and the intervening 
space is fifled with fiuid serum or pus. On showing postgraduate 
students such specimens I have witnessed complete failure of the entire 



PERICARDITIS 375 

class to recognize the organ before them, so great has been the change 
from the normal appearance. 

Symptoms. — Pericarditis is a disease which stands out pecuUarly 
because of the wide range of the possible sj^mptoms. Thus a case of 
purulent pericarditis may run its course under the observation of excel- 
lent clinicians and not be recognized until the autopsy, or the condi- 
tion may produce symptoms of the greatest urgency and occasion in- 
tense distress to the patient. It is, therefore, impossible to lay down 
a symptomatology for the disease that will apply to all cases. Peri- 
carditis is probably more frequently overlooked by clinicians than 
any other disease. 

An important symptom indicating pericarditis is rapid respiration. 
Not only is the breathing rapid, as in pneumonia, but it is fairly charac- 
teristic in that the respirations are guarded. The patient wears an 
anxious expression and appears to have his mind centered on breathing. 
Carefully guarded inspiration is taken and careful expiration is carried 
out. At the same time the respiration is hurried and short, although 
not precipitate. This cautious breathing is due to the feeling of de- 
cided discomfort, constriction, and even pain which accompanies the 
chest expansion. The respiration is somewhat similar to that of acute 
pleurisy. The individual is not sure that he will be able to complete 
respiration, and perhaps feels obliged to cut it short. 

The very rapid heart action is the most reUable symptom of the dis- 
ease, often exceeding in apparent severity all the other symptoms. I 
have repeatedly seen patients from eight to ten years of age with a 
temperature ranging only about 100°F., with a pulse-rate from 130 to 
150 or higher. 

Cyanosis is present. The expression is anxious. In my urgent 
cases a prominent symptom has been extreme restlessness. Discom- 
fort, pain, and a feeling of tension over the precordium are at times 
complained of. In other cases with apparently quite pronounced 
lesions there is httle or no discomfort. 

Diagnosis. — Pericarditis with rare exceptions is secondary to in- 
fection elsewhere. Thus in older children after the third year it is 
usually associated with endocarditis of rheumatic origin. I have seen a 
great many cases with this combination. In every case of endocarditis 
the physician should especially investigate the cause of exceptional 
rapidity of breathing and a rapid pulse. In younger children pericar- 
ditis is associated with pneumonia and empyema with greater fre- 
quency than with any other disease. 

Physical Signs. — The first evidence of pericardial inflammation will 
be a rubbing, grating sound heard over or sUghtly above the apex 
of the heart. The sound has a double quahty and is heard both at 
systole and diastole, or perhaps only with systole. The sounds are 
known as the pericardial friction sounds. In well-marked cases they 
will be transmitted to the finger on palpation. Wherever heard they 
are distinctly locaUzed. The right cardiac dulness forms an obtuse 
angle with the liver dulness, and in older children there may be bulging 



376 THE PRACTICE OF PEDIATRICS 

of interspaces. With the appearance of considerable fluid the friction 
sounds cease, but return when the fluid is absorbed. In cases in which 
the friction is questionable or indistinct, it will be accentuated by- 
having the child lean forward in a sitting position. 

Percussion. — When fluid in considerable amount is present, the area 
of cardiac dulness will be increased, the apex-beat will be difficult to 
determine, and the normal heart-sounds will become weakened. 

In a fatal case in a six-year-old boy the apex-beat was not demonstrable, find 
the heart-sounds could scarcely be heard. 

It has not been my observation that the apex-beat is displaced up- 
ward, as is claimed is the case in adults. With the presence of consider- 
able fluid, — over two ounces in a child from three to five years of age, — 
the dulness will be increased to the left and upward. 

With the larger effusion occurring in the boy above mentioned, the dulness 
extended to the right nipple and one inch outside of the left nipple. 

The amount of fluid is difficult to determine in any case, and particu- 
larly so when endocarditis and myocarditis coexist, with accompany- 
ing hypertrophy and dilatation. The duration of the acute cases of 
rheumatic origin varies from a few to a considerable number of weeks. 

Prognosis. — The prognosis in rheumatic cases is good if proper 
treatment can be followed. I have lost very few cases. We are deal- 
ing with a disease in which the management of the case determines to a 
large degree the outcome. Just how complete a recovery is made in 
the so-called recovery cases is difficult to determine, as there must be, 
in every case, adhesions between the heart and the pericardial sac. 
A condition known as adherent pericardium (p. 393) may be the out- 
come. The purulent cases, with so-called malignant endocarditis, 
have all been fatal, so far as my own observation is concerned. 

Treatment.— In considering the treatment we may divide cases of 
the disease into two groups — those of rheumatic origin and those due to 
the invasion of well-known pathogenic organisms. In the rheumatic 
cases the sick-room management and the diet are the same as in the 
treatment of endocarditis (p. 380). In addition to the management 
pursued in endocarditis, additional symptomatic treatment is required. 

For controlling excessive rapidity of the heart the tinctures of 
strophanthus and aconite may be of much service. To a child eight 
months to three years of age ^i drop of tincture aconite and one drop 
of tincture strophanthus may be given at two-hour intervals, but not 
to exceed six doses in the twenty-four hours. After the third year, one 
drop of the tincture of aconite and one drop of the tincture of strophan- 
thus may be given at two-hour intervals — six doses in the twenty-four 
hours. 

For the extreme restlessness which often exists codein or paregoric 
may be given. For a child under two years of age paregoric is safer. 
It may be given in doses of from 10 to 20 drops and repeated when 
indicated at intervals of two or three hours. Older children — between 



ACUTE ENDOCARDITIS 377 

the second and sixth years — should be given codein in doses of from 
Ko to }i grain. After the sixth year, 34 grain may be given, to be 
repeated at three-hour intervals only, not more than three doses being 
given in twenty-four hours. 

As soon as the diagnosis is made, if the case is of rheumatic origin, 
it is advisable to begin giving the salicylate of soda (wiDtergreen), with 
a view to prevention of an effusion into the pericardial sac. To those 
under three years, 14 to 20 grains of s'aUcylate of soda should be 
given daily with twice the amount of bicarbonate of soda. As the sali- 
cylate may cause some gastric disturbance, it should never be given 
when the stomach is empty, except in milk or with some other food; 4 
grains is as much as should be given at one time. After the third year, 
from 20 to 30 grains of the salicylate may be given. At the tenth year, 
40 grains may be given daily in divided doses, always in solution, under 
the same precautions as to giving the drug after meals. It is impossible 
and entirely unnecessary in this country to give the large doses of the 
salicylate which are given abroad. 

For delicate children and those by whom the salicylate is not well 
tolerated, aspirin may be substituted; or the salicylate may be given 
by the bowel, in doses of 15 grains at a time. The medicine should be 
diluted with at least 4 ounces of water and introduced through a rectal 
tube which has been inserted at least 9 inches. It should not be given 
oftener than twice daily, and should be immediately preceded by 
irrigation of the large intestine. 

In the comparatively infrequent cases in which pericarditis compli- 
cates one of the infectious diseases, the salicylate treatment is not to be 
advised unless there is some suspicion of rheumatism in the case. The 
other methods suggested are to be carried out with the hope that the 
disease may be controlled. In this type of case the ice-bag is particu- 
larly serviceable. In the event of effusion so excessive as to interfere 
with the heart action, producing orthopnea and cyanosis, with feeble, 
irregular pulse, operation on the pericardium, such as aspiration or 
incision and drainage, is to be considered, although in the few operative 
cases which I have seen I have not been impressed with the great useful 
ness of this treatment. On the other hand, I have seen cases, in which 
there was an excessive accumulation of fluid, recover under less radical 
measures. 

The Purulent Type. — When it becomes evident that pus is present 
in the sac, incision and drainage may be attempted, as the case will 
surely be fatal if the usual methods are pursued. In this type the 
blood shows a very high white cell count with very high polynuclears. 

ACUTE ENDOCARDITIS 

Acute endocarditis is an inflammation of the endocardium, or lining 
membrane of the heart. Probably in all cases showing even a moder- 
ate degree of severity there is involvement of the adjacent heart muscle, 
so that when there is an endocarditis, there is a myocarditis as well, 



378 THE PRACTICE OF PEDIATRICS 

although the latter may be of little moment. Pericarditis has been a 
complication in about 5 per cent, of my cases. In the great majority 
of instances endocarditis is to be looked upon as a manifestation of 
rheumatism and not a complication. 

Etiology. — Endocarditis is present in a considerable proportion of 
cases of chorea, the statistics of various authors varying from 6 to 55 
per cent. Both the chorea and the endocarditis are active manifesta- 
tions of acute rheumatism. In my own experience endocarditis has 
been present in not over 20 per cent, of the cases of chorea. Endo- 
carditis occurs as a complication of scarlet fever, diphtheria, measles, 
and tonsillitis. In fact, there are few diseases of bacterial origin with 
which it has not at some time been associated. In two of my cases it 
was a complication of grip. 

Age of Patients. — It is unusual to find endocarditis in children 
under three years of age. Few cases are seen between the third and 
fifth year. The period of greatest susceptibility is between the fifth 
and the twelfth years. 

Bacteriology. — The vegetative forms of endocarditis are more 
frequently due to rheumatism than to any other infectious disease. 
Poynton and Payne have demonstrated the diplococcus of rheumatism 
in the vegetations of the heart valves. The bacteria are readily 
found only in the early stage of the endocarditis, and tend to disappear 
in the later course of the disease. 

Acute ulcerative or septic endocarditis is more often a secondary 
than a primary condition, and is caused by the localization on the heart 
valves of bacteria from the blood-stream. The bacteria causing the 
primary infection are present in the valvular ulcers. Streptococci, 
staphylococci, pneumococci, gonococci, typhoid bacilli, colon bacilli, 
influenza bacilli, and diphtheria bacilli have been found. 

In chronic endocarditis no bacteria are demonstrable in the endo- 
cardial lesions. 

Pathology. — Inflammation of the membrane lining the heart affects 
chiefly the valves; and most frequently, those guarding the mitral and 
aortic orifices. The latter fact has been explained by a theory that 
bacterial development is better favored by the fresh arterial blood of 
the left ventricle than by the venous blood (of low oxygen-content) 
present in the right heart. 

The margins of the affected cusps are thickened and covered with 
small masses of necrotic tissue, fibrin, red corpuscles, leukocytes, pro- 
liferating endothelial cells, and bacteria. The chordae tendinese are 
frequently involved and undergo shortening, thickening, and a certain 
amount of fusion. In mild cases the integrity of the segments may not 
be lost, but more frequently, when the acute inflammation subsides, 
the valves undergo considerable cicatrization and contraction, and 
exist thenceforth as deformed and more or less ineflScient structures. 

In the severe forms of the disease, commonly termed malignant en- 
docarditis, destructive effects are much more marked, and ulceration of 
the mural endocardium may occur. In such cases emboli frequently 



ACUTE ENDOCARDITIS 379 

become detached from the friable vegetations on the valves, and may 
produce infarcts and abscesses in such remote organs as the brain, 
spleen, and kidney. 

The usual sources of infection are wounds of the skin and mucous 
membrane, and inflammation of the alimentary, pulmonary, and geni- 
to-urinary tracts. Prominent in this category undoubtedly are dis- 
eased tonsils. Attacks of ^'simple'' acute endocarditis may easily 
render the heart more susceptible to an infection of the malignant type. 

Symptomatology. — By far the majority of cases of endocarditis 
present no symptoms whatever. Hundreds of these cases are over- 
looked because of this peculiarity of the disease, and because writers of 
medical books, in describing the disease, lay great stress upon a symp- 
tomatology of prostration, high temperature, and severity in general, 
that may occur in one out of ten cases, the result being that nine are 
overlooked. A large majority of the cases of endocarditis coming 
under my observation (mild acute endocarditis, not chronic valvular 
disease) have been discovered in the routine examination of the 
patient, and not because anything in the case had suggested the heart 
as a factor in the illness. Every physician who does considerable 
cUnical work sees patients with valvular defects of long standing, who 
have no knowledge whatever that a heart lesion has existed. Those 
who examine for life insurance will particularly appreciate the force of 
the above statement. Children with rheumatic tendencies, as has been 
mentioned, are very susceptible to endocarditis. I have repeatedly 
seen cases develop after or with a tonsillitis in a child with a rheumatic 
tendency or inheritance, the endocarditis being the active manifesta- 
tion of the rheumatism. 

Illustrative Case. — A boy six years of age had a slight pain in his knee, which 
caused a limp. He had just recovered from a mild tonsillitis. In the routine 
examination an acute endocarditis was found, involving both mitral and the 
aortic valves. The boy made a complete recovery. 

There are doubtless many cases of endocarditis which pass unrecog- 
nized and recover. 

When symptoms are present, we find fever which presents wide 
variations, — 100° to 105°F., — depending upon the severity of the in- 
fection. The height of the temperature is usually a reliable indication 
of the gravity of the illness. With the high temperature there will be 
increased heart action — 110 to 140. If the action is irregular, myocar- 
ditis also may be suspected. Pain over the precordium and shortness 
of breath are usually present. 

Diagnosis. — The symptoms alone may be sufficiently pronounced 
to suggest the existence of endocarditis. It is by the physical signs, 
however, that suspicion is verified and the diagnosis made possible. 

Inspection. — Inspection, if it reveals anything abnormal, will show 
an excessive action of the heart, producing an undulating motion of the 
cardiac area, with visible apex-beat. 

Palpation. — Palpation confirms the existence of this overaction of 
the heart. 



380 THE PRACTICE OF PEDIATRICS 

Percussion. — Percussion may reveal cardiac enlargement. The left 
ventricle becomes dilated early in the severe cases. 

Auscultation. — Auscultation will reveal either a murmur (p. 369) or 
a combination of murmurs. In character the murmur may be soft 
and blowing, or harsh, rough, and grating. It may be systolic, 
diastolic, or presystolic; or it may be double, presystolic and systolic, 
or diastolic and systoUc. The fact that the left side of the heart is 
always involved simplifies materially the localization of the lesion. 

If due to mitral regurgitation, the murmur is usually soft and blow- 
ing in character, heard loudest at the apex, transmitted upward to the 
axilla, and plainly heard between the scapula and the spine. 

In mitral stenosis the murmur is presystolic in time, and is heard 
loudest just above the site of the apex-beat. This murmur is not 
transmitted elsewhere, and is accompanied by a thrill (p. 372). 

When there is combined mitral stenosis and regurgitation, the sys- 
tolic murmur follows immediately upon the presystolic, making a pro- 
longed murmur which completely obliterates the first heart-sound. 

Aortic stenosis produces a systolic murmur, heard loudest at the 
second interspace, over the middle of the sternum, or at its immediate 
right border, and transmitted upward to the carotids. 

In aortic regurgitation the murmur is diastolic in time and is heard 
loudest over the second and third interspaces. 

Differential Diagnosis. — Endocarditis may be confused with tem- 
porary functional disturbances of the heart, giving rise to functional 
murmurs (p. 372). This statement, of course, applies only to mitral 
disease. After many disorders in children in which the heart has been 
severely taxed, a soft, blowing, systolic murmur develops. This mur- 
mur, however, is inconstant, changes more or less, or disappears upon 
change in the position of the patient, and, most important of all, has 
no fine of transmission and is not heard at the back. After a few days 
or weeks, providing proper management is carried out, such murmurs 
disappear. 

Prognosis. — The outlook, in a great majority of cases of endocardi- 
tis, is favorable for a complete recovery. In other cases, even under 
the best of management, the patient, after recovering from the acute 
disease, is left with crippled valves. When there is a very severe in- 
fection of the so-called malignant type, the outlook is most unfavor- 
able. Recently a boy seven years of age died within forty-eight hours 
from the onset of the heart involvement. 1 have seen a considerable 
number of similar fatal cases in consultation work. The inflammation 
in such cases usually develops rapidly into a pancarditis, the heart 
muscle, the pericardium, and the endocardium all becoming rapidly in- 
volved, with resulting dilatation of the heart, which is often extreme. 

Treatment. — Rest in Bed. — Whatever the nature of the infection, 
and whether the disease is mild or severe, one rule — that regarding 
quiet and rest — must be consistently followed. The child must remain 
in a recumbent position in bed, the bed-pan being used to receive the 
discharges. The use of the arms and the hands should be discouraged, 



ACUTE ENDOCARDITIS 381 

particularly early in the attack, as it is at this time that the greatest 
damage is done to the heart. Reaching from the bed to the floor or to 
the table or chairs should be forbidden. The heart must be given as 
little work to do as possible. 

Prolonged Inactivity. — In both pericarditis and endocarditis absence 
of stress of any nature should be secured until every evidence of the 
disease has disappeared, or at least until the heart becomes regular, and 
its rate, under a test of moderate exercise, approximates the normal. 
The longest period I have kept a patient recumbent was six months. 
This patient is now a young man, and all that remains of his very ex- 
tensive endocarditis and pericarditis, comprising three distinct attacks, 
is a slight mitral regurgitant murmur with full compensation. Every 
patient is kept off the feet for at least six weeks, and several have not 
been allowed to take a step within three to six months. 

Diet. — The diet should consist largely of fluids, administered in 
comparatively small amounts, at shorter intervals than in health. The 
bowels should move once daily. If a laxative is necessary, a saline 
should be given. A SeidUtz powder or magnesium citrate is usually 
effective. Distention of the stomach, whether by gas or by food, 
causes pressure on the heart and increases its labor. It is my custom, 
in these cases, to give five feedings in twenty-four hours, and not more 
than eight ounces at a feeding. Four ounces of milk and four ounces 
of gruel, with zwieback or toast, constitute the usual feeding. In 
order to vary the diet, a weaker gruel. No. 1, flavored with an ounce or 
two of chicken or mutton broth, may be given; or a gruel of the same 
strength may be given plain, with sufficient salt to make it palatable. 
If the milk is well borne, it may be increased until one quart is taken 
daily. The enforcement of a strict milk diet is a mistake. The child 
very soon tires of it, digestion is impaired, and nutrition is correspond- 
ingly faulty. As the case improves, eggs, bread and butter, stewed 
fruit, poultry, fish, and plain puddings may be added to the diet. In 
order to facihtate freer feeding the number of meals should be reduced. 

The Ice-bag. — A screw-top ice-bag half filled with chopped ice 
should be placed over the heart, and, if possible, kept on continuously. 
Children frequently become restless and irritable under too constant 
application of the ice, and in such instances it may be left off occa- 
sionally for half an hour or an hour. 

Drugs. — In endocarditis following diphtheria or the exanthemata 
drugs are of little benefit. Salicylate of soda seems to have no bene- 
ficial effect upon these patients. For excessive rapidity of the heart 
action the tincture of strophanthus is more effective than any other 
drug. To children from five to ten years of age two drops may be given 
at intervals of from three to six hours. If there is much excitability 
and restlessness, }'i grain of codein or 8 grains of sodium bromid may 
be given at sufficiently frequent intervals to control the condition. 
While every case of non-rheumatic endocarditis presents possibihties 
of serious and permanent damage to the heart, not every case, by any 
means, is of sufficient severity to demand other treatment than the ice- 



382 THE PRACTICE OF PEDIATRICS 

bag, rest, and an easily digested diet. It is often the milder cases that 
occasion the gravest sequelae, on account of the lack of objective symp- 
toms, and the liberties given the child by parents, who are with 
difficulty convinced of the gravity of the disease. 

Antirheumatic Treatment. — Every case of endocarditis under my 
care which is not directly associated with one of the infectious diseases 
is considered and treated as though it were a case of rheumatism, owing 
to the exceeding frequency of this form of infection. Sodium sali- 
cylate, and sodium bicarbonate are early brought into use. To a child 
between five and ten years of age, from 3 to 5 grains of sodium saU- 
cylate obtained from wintergreen, with an equal quantity of sodium 
bicarbonate, are given after each feeding, five times daily. The medi- 
cine may be given in capsules or in solution. If the sodium salicylate 
is not well borne by the stomach, the equivalent dosage of aspirin or 
oil of wintergreen may be given. The salicylate should be continued 
with occasional intermissions of a day or two until such urgent symp- 
toms as fever, rapid heart-rate, and dyspnea have subsided. The 
dosage should then be varied, 10 grains being given daily for five days 
out of fifteen. A child who has recovered from rheumatic endocarditis 
should be kept under close observation, and the parents should be 
warned as to the possibilities of a second attack. 

Illustrative Cases. — In a private case, in spite of antirheumatic treatment, 
during the intervals four distinct attacks have occurred during the past five 
years. 

A dispensary patient at the New York Polyclinic had his first attack when four 
years of age. So prominent was his rheumatic tendency that during the next four 
years, in spite of active antirheumatic treatment and a careful diet in the intervals, 
he had eight distinct attacks of endocarditis and died from the heart involvement 
in his eighth year. There were other manifestations of rheumatism in his case, 
and his family on both sides for several generations had been markedly rheumatic. 

Recurrence. — Inasmuch as a recurrence is very probable, the patient, 
even while in apparent health, should have the benefit of a restricted 
diet, being allowed red meat but twice a week and a minimum amount 
of cane-sugar. During five days out of each month he should receive 
10 grains of sodium salicylate (wintergreen) and 10 grains of sodium 
bicarbonate daily. This scheme of medication should be continued 
for at least two years, and much longer if the patient shows any further 
rheumatic manifestation, such as pains in the legs or repeated attacks 
of tonsillitis. The length of time during which absolute rest in bed is to 
be enjoined depends on the severity of the case. This time, in my 
primary cases, is from six weeks to three months. In the case of a boy 
who had had a very severe second attack, walking was not allowed for 
six months, the patient using a wheel-chair instead. 

The rapidity of the heart's action is the best guide in deciding when 
the patient shall be allowed to walk. In a case of moderate severity 
the heart's action, which has been rapid, — 140 to 160, — gradually be- 
comes less frequent. The temperature may have continued for only a 
week or ten days. 



MYOCARDITIS 383 

Every child who has had acute endocarditis should have the tonsils 
enucleated. 

Convalescence. — When the pulse-beat is reduced to 100, which is 

not to be expected earUer than the fourth week, the patient may be 

allowed to sit in a recUning chair. Previous to this, while still in bed, 

he may be gradually accustomed to elevation of the head by the addi- 

:tion of an extra pillow for an hour or more daily. Greater freedom 

, is permitted when it is found that the patient can be indulged and the 

^heart-rate still be kept below 100. 

The above scheme of management may seem unnecessarily severe, 
but we must remember the importance of the heart in the economy, 
and see to it that if the patient cannot have a perfectly sound heart, it 
shall be damaged as little as possible. The treatment thus comprises 
the observance of every precaution that will tend toward the best 
possible outcome, no matter how drastic may be the requirements. 

MYOCARDITIS 

Myocarditis of mild degree is a frequent accompaniment of inflam- 
matory disease of the pericardium and endocardium. The most severe 
cases, however, may not be of this type. 

Etiology. — Acute parenchymatous myocarditis may follow various 
processes, but is most often due to the activity of the toxin of the pneu- 
mococcus, the typhoid bacillus, or the diphtheria bacillus. Inflam- 
mation of the endocardium or the pericardium may extend to the 
myocardium. 

Further references to the causation of this disease are included in 
the discussion of the pathology. 

Pathology. — Classifications of myocarditis are more or less artificial. 
Acute and chronic forms and parenchymatous and interstitial types of 
inflammation are recognized. 

Acute parenchymatous myocarditis usually results from an acute 
infection or toxemia, such as diphtheria, typhoid, or scarlet fever. The 
heart muscle is pale in color, soft, and somewhat friable. The heart 
itself may be dilated. Microscopically, the muscle-cells show granular, 
hyaline, and fatty degenerative changes, and frequently contain 
vacuoles; the nuclei stain imperfectly. In the interstitial tissue, poly- 
nuclear and lymphocytic infiltration and even some extravasation of 
blood may occur, these conditions being most marked in the neighbor- 
hood of blood-vessels. 

The reparative process is largely that of replacement fibrosis, a 
productive inflammation terminating in the substitution of fibrous 
connective tissue for the degenerated cells. Development of new 
muscle tissue also occurs. This, however, is probably brought about 
by simple hypertrophy of undegenerated muscle-fibers, rather than by 
true hyperplasia of these elements. 

Acute suppurative myocarditis may result directly from an abscess 
in the mediastinum or a purulent pericarditis, but is more frequently 



384 THE PRACTICE OF PEDIATRICS 

due to a general pyemia caused by the pneumococcus, streptococcus, 
staphylococcus, or gonococcus. The wall of the heart contains miliary 
pus foci and small extravasations of blood. Microscopic examination 
shows the vessels to be filled with embolic products, and surrounded 
by the small hemorrhagic areas and collections of pus-cells already 
described. The process, although essentially one of interstitial in- 
flammation, is regularly accompanied by considerable degeneration of 
the muscle-fibers. In the rare cases where recovery from suppurative 
myocarditis occurs, the defects in the heart are remedied by fibrous 
tissue. 

Chronic interstitial myocarditis in childhood is a productive repara- 
tive process, usually secondary to inflammation of the acute type. 
The development of this condition to compensate for atrophy of the 
heart musculature caused by defective blood-supply through partially 
occluded coronary arteries is essentially a change of later life. When 
due to syphilis, chronic myocarditis in children is usually accompanied 
by endarteritis. Gummata are rare, although Treponema pallidum 
may be demonstrated in the myocardium. 

Symptoms. — The most characteristic early sign of myocarditis 
in a child is a persistently irregular pulse, with or without a tendency 
to increased rapidity. It is not at all essential that the pulse be rapid 
— in fact, it is not at all unusual for it to be slower than normal. When 
such irregularity occurs after an acute disease, and particularly when 
there are occasional periods of cyanosis, myocarditis may be expected. 
It is often difficult to judge accurately of the heart's action when the 
child is awake, because of the excitement and possible resistance which 
the presence of the physician may occasion. For this reason, in sus- 
pected cases, the child should be examined, if possible, when asleep. 

When the child develops the above symptoms, he should be watched 
with the greatest solicitude, as the more urgent symptoms of pallor, 
marked cyanosis, and syncope may occur at any moment. The pulse 
becomes very irregular and thready, or it may be lost entirely at the 
Wrist, the patient presenting a picture of impending dissolution. In 
pneumonia, in septic cases of diphtheria, and in the exanthemata, the 
symptoms of acute myocarditis are those of early heart failure and 
are of grave significance. The pulse becomes rapid and irregular, 
cyanosis is constant, and the respiration is increasingly difficult be- 
cause of the sense of pressure and constriction in the cardiac region. 

Diagnosis. — The diagnosis is based upon the irregularity of the 
pulse following an acute infectious disease, and upon the sudden at- 
tacks of cyanosis and collapse. Auscultation is of value only in dem- 
onstrating the weakness and indefiniteness of the first sound. 

Treatment. — Rest in Bed. — When the condition of myocarditis 
follows even a mild attack of one of the infectious diseases, the invari- 
able rule of absolute heart rest, which I consider the most important 
feature in the treatment, must be insisted upon. The patient, whether 
in hospital or in private practice, should not be allowed to sit up or even 
to raise his head from the pillow; a trained nurse should remain con- 



MYOCARDITIS 385 

stantly in attendance, so that the child may be read to, or otherwise en- 
tertained while physical exertion is prevented. He may be permitted 
to use his arms, to play with simple hght toys, but all other exertion 
must be prohibited. Aside from provisions for the recumbent position, 
quiet, a daily bowel evacuation, and easily digested food, given in 
small quantities, httle treatment is required. It is important to keep 
the stomach free from distention with either gas or food. I prefer small 
quantities of nourishment administered at frequent intervals to large 
quantities of food given at the usual meal-time. 

Drugs. — In the more severe cases with cyanosis and dyspnea a 
hypodermic loaded with strychnin, 3^o grain, and digitalin, Koo grain, 
should be kept constantly at the bedside. 

In one of my cases following scarlet fever so urgent were the symptoms that 
three physicians were engaged for several days, each being for eight hours daily at 
the bedside, in addition to the two trained nurses, each of whom was doing twelve 
hours' duty. 

My patients have all been given strychnin, with the thought of 
possible associated involvement of the cardiac ganglion. Moreover, 
certain portions of the heart muscle obviously remain free from the de- 
generative process and may be favorably influenced by the strychnin. 
To a child one year of age Moo grain may be given three times daily. 
From the first to the third year, Moo to Moo grain may be given four 
times daily. After the third year the dose is subject to considerable 
variation, the amount depending upon the urgency of the case. Ordi- 
narily, from Moo to Ms grain may be given four times a day. If the 
case is very urgent and the strychnin appears to improve the heart 
action, it may be given to the point of producing its physiologic effects, 
such as fibrillary twitching of the muscles of the face and the backs of 
the hands. Nitroglycerin should not be used. Digitahs should be 
given but rarely to young children, as it is very apt to disturb the di- 
gestion if long continued; temporarily, in treating older children, it 
may be used with advantage. A child from five to ten years of age may 
be given daily (and preferably after meals) from three to four drops of 
the tincture well diluted with water. The tincture of strophanthus 
may be of more service than any other drug. It will be found particu- 
larly useful in those cases in which there is a tendenc}^ to rapidity of the 
heart action. A child one year of age may be given one drop every two 
hours in the twenty-four; from the first to the third year, from one to 
two drops at two-hour intervals; and from the third to the tenth year, 
from two to four drops at intervals of from two to three hours. 

Convalescence. — The tendency of myocarditis in children is toward 
recovery. How long each patient will require strict observation, and 
how long the treatment will ultimately need to be continued, must be 
determined by each individual case. One fact to be remembered, 
according to my cases, is that the child either dies suddenly or makes a 
complete recovery, so that in treatment it is well to err on the side of 
caution. I have found it safe, in a very few instances, to allow the 
child to sit up after six weeks. 
25 



386 THE PRACTICE OF PEDIATRICS 

In the very severe case above referred to it was not safe for the patient to sit up 
in bed until the end of the third month, and he was not allowed to walk until the 
end of the fourth month. After being kept under observation for one year he was 
discharged, and has remained well during the ten years which have since elapsed. 
At the present time there is no evidence whatever of his former illness. 

A safe rule to follow is to keep the patient in bed as long as the ra- 
pidity or irregularity of the heart exists. When the heart action in the 
recumbent position is apparently normal, the patient may be allowed 
to have his head raised by an additional pillow. In this way the head 
and shoulders may be gradually raised higher day by day, so long as the 
effect upon the heart muscle is not unfavorable. In the same way, 
standing and walking may be gradually begun. Following out this 
careful method of heart rest, and being governed solely by the heart 
action, which indicates the heart power, I have seen apparently hopeless 
cases completely recover. Whether fibrous changes are present which 
may have a later influence there is, of course, no means of knowing. 

CONGENITAL HEART DISEASE 

In congenital heart disease there is a structural fault. The heart 
in one or more respects is anatomically imperfect. 

Symptomatology. — Congenital heart disease is sometimes suggested 
by the appearance of the patient. There may be cyanosis, which is 
observed only when the child cries or strains, or the patient may be a 
'^blue baby," in which case the cyanosis is permanent and of such a 
degree as to make the diagnosis positive without further aid than 
inspection. 

By far the greater number of my cases have been discovered in the 
routine examination and had presented no external sign whatsoever 
that a lesion existed. 

Prognosis. — The future of the child with the congenitally defective 
heart is very uncertain. I have seen a very few of these patients go on 
to the adult period of life and suffer no inconvenience. In by far the 
larger number, however, the approach of the runabout and active 
period (if the child survives to this time), with the extra demand upon 
the organ that this age necessitates, results in failure of compensation 
and dilatation, followed by the usual train of symptoms peculiar to 
right heart failure. 

A girl with congenital heart disease developed several attacks of angina and 
cyanosis at the thirtieth month. This continued at rather infrequent intervals 
for a year, when she died in an attack. 

Pathology. — The initial and chief lesion in the majority of cases is 
at the pulmonary orifice, and is supposedly due to a fetal endocarditis 
which causes a stenosis at this orifice, which in time, through interfer- 
ence with the blood-current, prevents a closure of the auricular or 
ventricular septum. 

Cases are occasionally seen, however, in which the defect in one or 
other of the septa exists without atresia or stenosis at the pulmonary 
orifice. 



CONGENITAL HEART DISEASE 387 

Patent ductus arteriosus is rare. Its presence is usually associated 
with other defects, such as pulmonary obstruction and septum defects. 

Changes in the great vessels are occasionally encountered. Thus, 
the aorta may have its origin from the right ventricle, and the pul- 
monary artery from the left ventricle. 

Cardiac Enlargement. — Enlargement of the heart is the rule in 
congenital cases. Usually the right heart will be found particularly 
involved. 

The above conditions represent some of the more common abnor- 
malities. One who has observed many autopsies upon children has had 
abundant opportunity to verify the above statements and to see other 
abnormalities which are of academic interest only. 




Fig. 47. — Clubbed fingers in congenital heart disease. 

Classification of Lesions. — It is a hopeless task to attempt to 
classify a congenital lesion according to the nature, maximum intensity, 
or transmission of the murmur. I have seen this attempted time and 
again, the autopsy showing results that were not flattering to the 
diagnostic acumen of the examiner. 

Diagnosis in Infants and Very Young Children. — The most sugges- 
tive feature relating to diagnosis is a pronounced cardiac murmur in a 
child under eighteen months of age. Children before this period of life 
rarely have rheumatism, which is the cause of endocardial lesions in 
over 95 per cent, of the cases. The absence of cyanosis is no evidence 
against the diagnosis of a congenital lesion, as a great majority of my 
cases have not shown this symptom. On the other hand, there may be 
a marked degree of cyanosis and not the slightest trace of a murmur. 
At autopsy such a case showed an entire absence of the ventricular 
septum. 



388 THE PRACTICE OF PEDIATRICS 

First, then, the age of the child is strongly suggestive as to whether 
the condition is due to a congenital abnormality or an acquired disease. 
If the patient is under eighteen months of age or even under two years, 
the lesion is in all probability congenital. 

Second in importance I would place the character of the murmur, 
which is usually systolic and of a very loud, rasping character, heard 
loudest in the third or fourth left intercostal space with a very wide 
area of diffusion. Many of these murmurs may be heard over the 
entire thorax, both anteriorly and posteriorly. 

Differential Diagnosis in Infants. — At this period of life the murmur 
of congenital heart disease has to be differentiated from the murmur 
found in anemia. Not all congenital murmurs are as characteristic 
as above described. They may lack the element of loudness and 
harshness and be soft and blowing in character. This, however, is of 
very infrequent occurrence. In such an event a differential diagnosis 
between a congenital cardiac lesion and a murmur due to anemia is 
most difficult, for the anemic inurmur is systolic in time, is heard loud- 
est over the base, and has a fairly evenly distributed area of diffusion in 
all directions. 

In such cases the blood examination is of decided service. In con- 
genital heart disease there is almost constantly a very extreme poly- 
cythemia with high hemoglobin percentage and specific gravity, and a 
moderate increase in the white cells (Wood). 

Murmurs Constant. — This fact is a valuable aid in differentiation. 
Murmurs due to a lesion are constant and vary little under different 
states. Whether the patient is at exercise, at rest, sitting, standing, or 
lying down, the murmurs are invariably present and vary only in 
intensity. 

The Functional Murmur. — The chief characteristic of the functional 
murmur is the inconstancy of the sound, now loud, now weak. Not in- 
frequently these murmurs disappear under stress and reappear when 
the stress is removed. They may disappear or become very faint with 
the patient recumbent, and reappear upon the return to the erect po- 
sition. A relaxed heart muscle might be a cause of some of these cases. 

The anemic murmur changes upon change in position of the patient, 
and during exercise it is inconstant. 

Diagnosis and Differential Diagnosis in Older Children. — In chil- 
dren after the second year the differential diagnosis may also be difficult. 
It is to be remembered that in cases in which a congenital murmur is 
well marked at this period of life there will usually be other signs that 
may aid us in our judgment. Cyanosis is present in a larger proportion 
of the older patients than of the very young. This is to be explained by 
the fact that the child, when very young, calls upon the heart to a 
comparatively small extent. With the assumption of active play and 
with running, stair-climbing, and stress of any nature, the defective 
heart fails to meet the extra demands, and cyanosis, clubbed fingers 
(Fig. 47), and shortness of breath develop. At this age, also the ques- 
tion of anemia and developmental conditions arises. I have repeatedly 



CHRONIC VALVULAR DISEASE OF THE HEART 389 

seen patients who showed no inconvenience whatever until this more 
active period of hfe was reached. 

Murmur After Illness. — The murmur of congenital disease is also 
to be differentiated from other functional murmurs than those of 
anemia (p. 403), which are practically all systolic in time and have a 
wide area of diffusion. These functional murmurs often occur during, 
or particularly after, severe illnesses, such as pneumonia or typhoid 
fever, when the heart has been severely taxed. With such a murmur 
there is no accentuation of the second sound, no accompanying dropsy 
or cardiac enlargment, and the murmur is inconstant and variable 
being influenced by the activity of the heart and the position of the 
patient. 

CHRONIC VALVULAR DISEASE OF THE HEART 

Chronic valvular disease of the heart (acquired) is the end-result of 
an endocarditis which has resulted in certain changes in the valves and 
cardiac orifices, producing a permanent lesion. The acquired lesion in 
children will practically always be found on the left side of the heart, 
involving the mitral and aortic valves. With such lesions, compensa- 
tory hypertrophy, a conservative process, is usually associated. 

Etiology. — A most important feature to keep in mind in connection 
with valvular disease of the heart in children is the source of the dis- 
ease. A large proportion of the cases (95 per cent, in my own experience) 
are due to rheumatic endocarditis. In the absence, then, of a history 
of endocarditis in association with pneumonia, diphtheria, or scarlet 
fever, which in my experience has been of rare occurrence, it may be 
assumed that the valvular lesion is of rheumatic origin, even though 
there may not be elsewhere, at the time, positive evidence of rheuma- 
tism. Not a few children showing cardiac disease without a history of 
actual acute rheumatism have a history of tonsilHtis, angina, coryza, 
asthmatic bronchitis, or chorea, all showing recurrent tendencies. 
Such patients will often be found to have a rheumatic or gouty ances- 
try, and not infrequently they themselves are hearty eaters of red meat 
and sugars. 

The great majority of cases of valvular defects recognized in early 
adult life are the result of unrecognized endocarditis of childhood. 

Janeway* finds that proved bacterial endocarditis is one of the rare 
causes of chronic valvular disease. 

Symptomatology. — Chronic valvular disease in children may exist 
unchanged for years if the lesion is not severe and if compensation is 
maintained. 

The first symptoms of failure of compensation are shortness of 
breath and rapidity of heart action, both of which the child will mention 
in describing the condition. If the heart is not relieved, the patient 
will soon present evidence of right heart involvement, such as persist- 
ent general bronchitis, inability to assume the recumbent position, 
dropsy, and enlargement of the liver and spleen. Later the breathing 
* Boston Med. and Surgical Journal, vol. clxxiv, No. xxvi. 



390 THE PRACTICE OF PEDIATRICS 

becomes more difficult, the expression anxious, and the face drawn and 
cyanosed upon the sHghtest exertion. The superficial veins become 
dilated, and the pulse finally becomes very irregular and soft. Death 
in children with this disease is usually due to terminal broncho- 
pneumonia. 

Diagnosis. — Valvular lesions are indicated by adventitious heart- 
sounds, known as murmurs (p. 370), which are heard either with, or 
in place of, the normal sounds (p. 368). 

The character, time, point of maximum intensity, and area of trans- 
mission indicate the location, and to a fairly accurate degree the 
nature, of the lesion. 

Prognosis. — The prognosis depends to a large degree upon both the 
location and the nature of the lesion. In mitral regurgitation with 
good compensation the possibilities for long life are favorable, depend- 
ing somewhat, of course, upon the age and condition of the patient. 
If the case is of long standing, the possibility of a complete cure is not to 
be considered. An unknown factor in these cases which has important 
bearing upon the future is the possibility of reinfection. When rheu- 
matic endocarditis has once existed in a child it is liable to return ; and 
in the event of recovery from a second or third attack, the heart is left 
in a more serious condition than ever before. 

Mitral regurgitation with good compensation may not seriously in- 
convenience the individual for years if careful habits of life are fol- 
lowed. Neither need a mild degree of uncomplicated aortic stenosis 
cause great anxiety. Nevertheless, I always look upon stenosis at 
either the mitral or aortic orifice with apprehension, and my own re- 
sults with the stenosis cases during years of observation have been far 
from satisfactory. Aortic regurgitation is often associated with 
aortic stenosis, and the outlook for such patients as well as those with 
mitral stenosis is not favorable as regards the duties of active adult Ufe. 

If there is one word more than another that typifies the life of a 
child, it is the word ''stress." Activity and excitement are so in- 
herently a part of child life that the heart crippled by aortic dis- 
ease is often called upon to do work which is impossible. Even if 
the patient attains the fifteenth year without loss of compensation, 
the heart is in a condition that entails semi-invahdism. 

Treatment. — Realizing that rheumatic endocarditis is very likely 
to return, we should make it our first duty, after acquainting ourselves 
with the probable origin of a given case of valvular disease, to explain 
to the parents that other attacks are liable to occur unless means are 
used for their prevention. Enucleation of the tonsils should be 
practised here as after acute endocarditis. 

In the absence of a history of endocarditis in association with pneu- 
monia, diphtheria, scarlet fever, or other infections, it may be assumed 
that the lesion is of rheumatic origin, even though a history or actual 
evidences of rheumatism may be lacking. 

Our first step in the management must be to regulate the life so as 
to prevent a recurrence of the heart involvement. With this end in 



CHRONIC VALVULAR DISEASE OF THE HEART 391 

view, it shoud be directed that red meat be given the child but once 
every second day, and that cane-sugar be given in great moderation. 

A diet of plain, nutritious food, with nothing between meals, is a 
very important feature in the treatment of heart disease in children. 
Poultry, fish, eggs, milk, and high-proteid cereals may be given in in- 
creased amount in order to maintain nutrition. A tub-bath followed 
by a dry rub should be given daily. The bowels must not be allowed 
to become constipated, and moderate exercise should be encouraged. 

Drugs Advised. — For five successive days out of each month a 
patient from five to ten years old should be given, after meals, 5 grains 
of salicylate of soda (wintergreen) and 10 grains of bicarbonate of soda. 
This, with the low meat and low sugar diet, is usually, but not invari- 
ably, sufficient to prevent a recurrence. Occasionally I have been 
obliged to give the above treatment for five days with intervals of 
only ten days. An interesting result of this treatment has been an 
entire disappearance of the growing pains, recurrent bronchitis, or 
low grade eczema, with which the child may have been afflicted. 

Drugs Used With Caution. — The further management of valvular 
disease depends to a certain degree upon the location and nature of the 
lesion. Because a child has a cardiac lesion he does not necessarily 
require digitalis. Not a little harm is done, in the treatment of diseases 
in children, by giving powerful drugs when they are not indicated. Too 
often in heart disease the physician feels his duty done when he gives 
digitalis. Many times I have seen children taking digitalis and strych- 
nin because of some cardiac lesion, while, at the same time, they were 
suffering from constipation, recurrent respiratory disorders, and per- 
sistent indigestion due to dietetic errors, all of which had escaped the 
attention of the physician. 

Mitral Regurgitation. — In mitral regurgitation, well compensated, 
the activities need be but little curtailed; in fact, the patient may be 
encouraged to indulge in outdoor exercise, although competition in aU 
games requiring unusual exertion, tests of speed or endurance of any 
nature, such as running and racing, should be forbidden. When the 
patient is old enough, swimming, bicycling, horseback-riding, and golf 
may be advised. Boys, on arriving at the tobacco and alcohol age, 
must be told the dangers attending the use of either drug, and both must 
be forbidden. Girls with mitral insufficiency must be warned against 
excessive dancing, rope-jumping, tight lacing, and indiscriminate 
eating. For patients of both sexes, rational exercise is beneficial. 

Mitral Stenosis and Aortic Disease. — When the aortic valves are 
involved either in insufficiency or stenosis, or when there is a consider- 
able degree of mitral stenosis, the child's activities should be consider- 
ably limited. Under these conditions, with a view to the future, re- 
gardless of satisfactory existing compensation, I forbid the bicycle, 
swimming, dancing, baseball, or any sport or game which may call for 
much physical effort. Plenty of entertainment may be provided which 
does not call for great physical effort. The nature of the disease should 
be fully explained not only to the parents, but also to the patient, when 



392 THE PRACTICE OF PEDIATRICS 

the latter is old enough to understand, so as to secure hearty coopera- 
tion in governing the child's activities. Moreover, parents should be 
told particularly that tonsillitis or angina is a danger-signal, and 
that, on the occurrence of either condition, the saHcylates are to be 
brought into use at once, even before the physician is summoned. 

Ordinarily, it is not well to talk over a child 's ailments with him or 
in his presence. To older children with cardiac disease, however, I 
explain as clearly as possible the nature of the illness, and insist that 
certain measures, particularly such as relate to restriction of activity, 
shall be carried out indefinitely. I find that in this way better coopera- 
tion on the part of the patients is secured than if they are simply given 
a list of dogmatic "don'ts." It is, furthermore, my custom, in cases 
showing aortic involvement or mitral stenosis, to advise what is known 
as *' heart rest.'' Every day after the midday meal, with clothing 
off or loosened, the child should be made to rest in a recumbent posi- 
tion for at least one hour. During this time he may sleep or read, as 
best suits his individual taste. 

Constructive Medication, — As most of the cases of valvular disease 
in children are of rheumatic origin, it will be found that the majority 
of the patients are suffering from a mild degree of anemia. All the 
benefits of good nutrition, fresh air, and regularity in living referred to 
under Tardy Malnutrition (p. 100), should be afforded these children. 
Iron alone or with arsenic is here of some value when given with a suit- 
able diet. A method often followed is to give, for five days, the 
salicylate and bicarbonate of soda already referred to ; for fifteen days 
iron and arsenic; and during the remaining ten days of each month no 
medication, unless cod-liver oil is well borne, in which case this may 
well be given in combination with the extract of malt. If the patient 
can swallow a capsule, the following is given: 

I^ Liquoris potassii arsenitis gtt. xc 

Extracti ferri pomati gr. x 

Quininse bisulphatis 5j 

M. ft. capsulae no. xxx. 

Sig. — One after each meal. 

If the iron produces constipation, }i to J^ grain of the extract of 
cascara may be added to each capsule. 

Heart Stimulants. — Aside from such tonic medication, drugs af- 
fecting the heart itself should not be given unless compensation fails. 
This may take place temporarily, regardless of the nature of the lesion, 
after some forbidden exercise, or during an acute illness sufficient to 
produce prostration. Such failure may occur permanently in cases 
which, for any reason, do badly. In the event of defective com- 
pensation and dilatation, the child should be kept in bed until the 
normal heart action is restored by rest, or until it is demonstrated that 
the aid of heart stimulants is required. In these cases, particularly 
in those of the latter type, when there is a rapid, irregular pulse, dif- 
ficult breathing or excitement, and dropsy, the time-honored remedy, 
digitalis, is to be brought into use. For children I prefer to use the 



ADHERENT PERICARDIUM 393 

tincture. To a child from five to ten years old from 3 to 5 drops may 
be given after meals three or four times daily. This drug, because 
of its well-known irritant effects upon the stomach, should be given 
considerably diluted. Its beneficial effects will be apparent first in 
the relief of the dyspnea, the pulse becoming regular and of increasing 
volume; and later in the increased secretion of the kidneys and the 
disappearance of the edema. The amount of digitalis given should be 
reduced as soon as the condition will allow, but the medicine should 
be continued for a considerable time after the patient is up and about. 
The only contraindication to the use of digitalis in children is its effect 
upon the stomach. This is often so unfavorable that loss of appetite 
results, in which case the preparations should be discontinued. In 
this event the tincture of strophanthus, which is referred to repeatedly 
in this work as a heart stimulant, may be substituted in the same doses. 
In cases requiring a cardiac stimulant for a considerable time or 
permanently I have had satisfactory results by alternating the digitaUs 
with the strophanthus, giving each for five days. The child, however, 
who requires constant cardiac stimulation promises but little for the 
future, and, in my experience, few patients of this type have survived 
the eighteenth year. 

ADHERENT PERICARDIUM 

As a result of an unresolved pericarditis with which a myocarditis 
may or may not have been associated, adhesions exist which bind the 
pericardium to the heart muscle, in most instances completely obhter- 
ating the pericardial sac. The condition is found in cases in which 
there is extensive cardiac disease, such as hypertrophy, dilatation, 
and valvular involvement. 

Diagnosis. — Diagnosis, if made at all, is usually made at the autopsy. 
The diagnostic sign of real differential value is a restriction of the chest- 
wall in the interspace corresponding to the apex-beat. Sometimes per- 
manent cardiac friction-sounds may be heard, and there usually is an 
increase in the cardiac dulness to the right over the sternum. 



X, THE BLOOD AND BLOOD DISEASES 

BLOOD IN THE NEWLY BORN 

According to Schiff, Perlin, Carstanjen, Scipiades, and Takasu, 
the blood of a new-born babe exhibits numerous characteristic changes. 

1. The specific gravity averages between 1.060 and 1.080, but 
during the first two weeks rapidly" sinks to its lowest point, at which it 
usually remains until the end of the second year of life, after which 
it rises until puberty, the average thus being between 1.050 and 1.055. 

2. The percentage of hemoglohin is very high— usually between 
100 and 140 per cent, of that found in the healthy adult. 

3. The red cells, which are greatly increased, may number as high 
as 7,550,000, and usually above 5,000,000. 

4. The white cells are also increased, in one case numbering 36,000. 

5. According to Carstanjen, the polymorphonuclears number 73.4 
per cent., as compared with 16.05 per cent, lymphocytes. 

6. A large number of nucleated red cells are present up to the sixth 
day, after which scarcely any are to be found. 

The variations noted become less marked after the fourth day. 
The number of polynuclear leukocytes diminishes, and after the fourth 
day the percentage of the various kinds of leukocytes is fairly constant 
during the first few months. 

It is suggested that many blood-changes observed in the new- 
born are due to the lack of water, a considerable amount of which is 
lost through the intestine and in the form of perspiration. 

BLOOD IN INFANCY OR CHILDHOOD 

Hemoglobin. — Throughout the period of infancy and childhood the 
hemoglobin is lower than in the adult, its minimum being usually 
reached between the third month and the second year. From this 
point it gradually increases until puberty. The average hemoglobin 
of childhood is between 65 per cent, and 85 per cent., the former 
being considered a low limit for a healthy child. 

Red Cells. — The average number in infancy is from 4,000,000 to 
5,500,000, and in later childhood from 4,000,000 to 4,500,000 (Hayem). 
In the blood of the fetus and in premature infants nucleated cells are 
seen, but in later infancy their presence must always be considered 
pathologic. Formerly their occurrence even in healthy children was 
considered the rule. 

Normal White Corpuscles. — In health the following varieties are 
found : 

1. Lymphocytes. — These cells are smaller (5 to 8 microns in diame- 
ter), or larger (8 to 10 microns), than the red blood-cells. The 
nuclei are relatively large, round, deeply stained, centrally placed, and 

394 



BLOOD IN INFANCY OR CHILDHOOD 395 

contain one or two nucleoli. The cells may be deeply notched, es- 
pecially the smaller ones, and even suggest polymorphonuclear cells, 
but are never identical in appearance. The protoplasm forms a 
narrow rim around" the nucleus and is sometimes reticulated. The 
nucleus stains with basic dyes more faintly than the protoplasm. The 
larger cells of this group have an irregularly staining nucleus with a 
chromatin network and a margin of faintly granular protoplasm. 
The lymphocytes constitute from 40 to 60 per cent, of the leukocytes 
in the normal infant's blood. 

2. Large Mononuclears. — These are not polymorphous cells, but 
contain a single round or large oval nucleus, and are usually two or 
three times as large as red blood-cells. The protoplasm is homogene- 
ous and relatively large in amount. These cells constitute about 4 
to 6 per cent, of the leukocytes. 

3. Transitional Cells. — These are usually larger than the large 
mononuclears, which they closely resemble ; in fact, they are the largest 
cells of the blood. They possess a 'Vallet" or ^'saddle-bag" nucleus. 
During the first few months they comprise 8 to 10 per cent, of the white 
cells (Carstanjen, Karnizki). 

4. Polymorphonuclear Neutrophiles. — These cells, which constitute 
from 18 to 40 per cent. (Emerson) of the child's blood, are somewhat 
smaller than the transitional cells. The nucleus is characterized by its 
polymorphous nature and its deep stain, while its protoplasm is well 
filled with neutrophile granules, which may cover the nucleus. 

5. Eosinophiles. — These are usually of the same size as the pre- 
ceding, and occasionally a little larger. The nuclei are fairly well 
stained, while the protoplasm is filled with large eosinophilic granules. 
These cells constitute 2 to 4 per cent, of the normal white ceUs. 

6. Mast Cells. — These are about the same size as the preceding, 
but frequently smaller; they have a trilobed nucleus and a protoplasm 
containing many large basophilic granules; often they are metachro- 
matic. Their proportion is about 0.5 per cent, of the white cells. 

Leukocytes Found in Pathologic Conditions. — 

1. Myelocytes. — While any cell of bone-marrow is, strictly speaking, 
a myelocyte, by this term is generally meant one with a round nucleus 
and a granular protoplasm. Neutrophilic and eosinophilic myelocytes 
occur. Their size varies from that of the large mononuclears to that of 
red corpuscles. The nucleus is round, oval, and sometimes kidney- 
shaped, but never polymorphous; it is usually centrally placed, and is 
not stained diffusely by any good nuclear dye. The protoplasm may 
contain many or few granules of the neutrophilic type. 

2. Eosinophilic Myelocytes. — These resemble the polynuclear eosino- 
philes, except for the rounded, undivided nucleus. 

In pathologic conditions the leukocytes undergo various degrees of 
degeneration, both acute and chronic. There may be swelling, frag- 
mentation, and hydropic and fatty degeneration, with nuclear changes. 

According to Rieder, the leukocytes average from 8700 to 12,400 
between the second and fourth days; after the fourth day, from 12,400 



396 THE PRACTICE OF PEDIATRICS 

to 14,800. In infancy the variations are from 9000 to 14,000; in later 
childhood, from 6000 to 12,000. When the second year is reached, the 
blood gradually begins to assume the adult type. This, however, is 
not attained until the fifteenth or sometimes the twentieth year. Up 
to the sixth year there is a preponderance of lymphocytes. Sex makes 
no material difference until the fifteenth year. The blood-making 
organs of the infant are severely affected by disease. The infantile blood 
readily takes up myelocytes and nucleated cells (Zelenski-Cybulski). 

Leukocytosis. — By this is meant an increase in the number of white 
corpuscles in the blood. It may be of two varieties — relative and abso- 
lute. A relative leukocytosis is more frequent in children than in 
adults. By the leukocytosis one may judge the nature of the reaction 
of the organism to bacteria or to the toxins in the blood elaborated 
by the bacteria concerned in the inflammation or infection. It may 
thus be seen that the reaction of the individual will depend upon 
two factors: (a) the severity of the infection and (b) the resistance 
of the individual. Of the two, the latter is more important. It is a 
fact that the most marked degree of leukocytosis is observed in a 
healthy, well-nourished child suffering from a severe infection ; while, 
on the other hand, a feeble child suffering from the same infection 
will have a slight leukocytosis or probably none at all. The nature 
of the infection depends upon the character of the inflammatory process. 
Leukocytosis is less marked in serous and more pronounced in suppu- 
rative processes, while in both instances it is highest during the stage 
of active exudation. In well-localized suppurative inflammations 
there may be no leukocytosis at all. 

Leukocytosis is present in a great many pathologic conditions, and 
in some cases the explanation is wanting. A satisfactory division of 
leukocytosis is into the two groups — (a) physiologic and (6) pathologic. 
By the former is meant that which follows a meal or exercise or that 
which occurs in the new-born ; by the latter is meant that which may 
occur after serious hemorrhage, maligant disease, and various inflam- 
matory and toxic conditions. Japha has not been able to demonstrate 
a genuine leukocytosis of digestion in the bottle-fed infant, and Greger 
did not even find it regularly present in the breast-fed infant. If, how- 
ever, a breast-fed infant was given cow 's milk, there was an immediate 
occurrence of leukocytosis and hence the opinion (Moro) that it is a re- 
action against foreign proteid. Children show a more pronounced 
digestive leukocytosis than adults, occasionally the increase amount- 
ing to one-third of the total number of leukocytes. 

The chief form of leukocytosis in children is the inflammatory type. 
This is especially noticeable in acute pneumonia, diphtheria, acute 
rheumatism, erysipelas, scarlet fever, tuberculous meningitis, and in 
suppurative conditions of the subcutaneous tissues, serous cavities, 
bones, joints, and viscera. In these conditions the increase is chiefly 
in the polymorphonuclear neutrophiles. 

In pertussis, hereditary syphilis, and certain diseases of the spleen 
there is a relative increase in the lymphocytes, while in leukemia, 



THE BLOOD IN DIFFERENT DISEASES 397 

asthma, helminthiasis, and some forms of chronic skin disease there 
is an increase in the eosinophils. 

There is usually no leukocytosis in typhoid fever, measles, rotheln, 
mumps, malaria, and uncomplicated tuberculosis not invading the 
meninges or serous surfaces. In the usual forms of gastro-enteritis 
leukocytosis is absent, while in ''Finkelstein's alimentary food intoxica- 
tion " it is pronounced. 

THE BLOOD IN DIFFERENT DISEASES 

Pneumonia. — In this disease there is regularly a leukocytosis, and 
it is in this illness that the inflammatory leukocytosis has best been 
studied. The leukocytosis here is an expression of the resistance of 
the organism to the infection, and depends but little on the fever and- 
the extent of consolidation (Ewing). In an average case the count may 
vary between 15,000 and 40,000 or 50,000, and but rarely reaches 
100,000; although there are a number of cases on record with a count 
as high as this. A high count gives no idea of prognosis; it means that 
the protective forces are making a vigorous fight, but gives no hint 
as to which will win, they or the infection. Absence of leukocytosis is 
usually of bad import, and shows that the patient has low resistance; 
and a rapid fall with either a low or a high temperature is usually 
indicative of a loss of resistance on the part of the patient. The fall 
in the count begins just before, just after, or with, that of the tempera- 
ture, and may be by the maximum count; this diminution usually 
corresponds to the change in temperature. If the count remains ele- 
vated, delayed resolution, empyema, or abscess should be suspected. 
The increase is mainly in the polymorphonuclear cells, which may vary 
from 60 to 90 per cent, of the total leukocytes. In pneumonia following 
pertussis the increase is chiefly in the lymphocytes. The absence of a 
leukocytosis in a strong, well-nourished child who is very ill is always 
strong presumptive evidence against pneumonia. The changes in the 
red cells and hemoglobin are those of a secondary anemia, depending 
on the duration of the disease and the resistance of the patient. 

Leukocytosis is present in both forms of pneumonia in infancy and 
childhood, but is more marked in the lobar form, the number of leu- 
kocytes to the cubic millimeter being about twice as many as in the 
catarrhal types. There is marked leukocytosis in the fatal cases of 
both forms of pneumonia (Koplik). 

Empyema. — Marked leukocytosis is almost invariably present with 
a high polymorphonuclear count — usually from 75 to 90 per cent. In 
cases of long standing there is often no leukocytosis, but the poly- 
morphonuclear count remains elevated. In tuberculous effusions the 
count is usually low, with no increase in the polymorphonuclear count. 

Influenza. — Uncomplicated influenza has no leukocytosis. In- 
fluenzal pneumonia ordinarily has a leukocytosis of from 15,000 to 20,- 
000. To date no uniform conclusions have been arrived at concerning 
any characteristic change in the differential count other than that of 
an ordinary pneumonia. 



398 THE PRACTICE OF PEDIATRICS 

Tuberculosis. — In tuberculosis, in general, there exists a mild grade 
of chlorotic anemia with little or no leukocytosis. The count is nearly 
normal, while the hemoglobin is somewhat reduced. In other cases 
there is a lymphocytosis, absolute or relative. If a secondary infection 
occurs, which is not infrequent in infants and young children, leukocy- 
tosis is the rule, and, in fact. Limbeck considers the presence of a 
leukocytosis sufficient guarantee of a secondary infection. In case of 
pneumonia the leukocytosis is as high as in the ordinary croupous 
pneumonia. Various observers are of the opinion that in incipient 
tuberculosis there is a slight increase in the eosinophiles, and that, as 
the infection progresses, they diminish. From a series of 182 blood 
examinations of tuberculous patients Solis-Cohen concludes that an 
increase in the polynuclear count points toward an advance of the 
disease and vice versa. In tuberculous bronchial adenopathy and 
peritonitis, leukocytosis is absent, although in the latter Cabot reports 
an increase in the cell count in 14 out of 60 cases. Tuberculous men- 
ingitis regularly causes a leukocytosis, reaching at times as high as 
50,000, while there is usually a polymorphonucleosis, in some instances 
as high as 90 per cent, of the total white cells. In bone and joint 
disease the leukocytes are normal or very slightly increased, and only 
during abscess formation or following operation is there an appreciable 
increase in the cell count. 

Typhoid. — As in adults, there is a low white cell count, generally 
under 10,000. The lymphocytes are shghtly increased, and there is 
usually a mild grade of anemia. 

Rheumatism. — There is regularly a leukocytosis and a severe grade 
of secondary anemia. 

Peritonitis and Appendicitis. — In the former there is a polymorpho- 
nuclear leukocytosis. This, however, is wanting in some cases of the 
severest type. In a series of 70 cases of appendicitis in children re- 
ported by Fowler in 1912, the average leukocyte count was 19,106, 
the average polynuclear, 79.7 per cent.; the highest leukocyte count 
was 48,200; the lowest, 8200; the highest polynuclear count, 92 per 
cent. ; the lowest, 63 per cent. 

Meningitis. — In cerebrospinal meningitis and in meningitis caused 
by the other pyogenic organisms there is regularly a leukocytosis with 
an increase in the polymorphonuclears. The leukocyte count is of no 
value in distinguishing the various forms of meningitis, since it is also 
present in the tuberculous form (Emerson). 

Poliomyelitis. — Until a monograph on poliomyelitis by Draper, 
Peabody, and Dochez, of the Rockefeller Institute, was. issued, a num- 
ber of conflicting statements had been made concerning the blood 
findings in this disease. Previous to this clinical study by the above 
authors, Miiller in Germany, and La Fetra in New York, had made the 
most extensive observations. The latter reported a leukocytosis 
between 13,400 and 20,600, while Miiller found a leukopenia in the 
acute stage. Draper, Peabody, and Dochez tabulated their findings in 
59 hospital cases, and came to the conclusion that in the preparalytic 



THE BLOOD IN DIFFERENT DISEASES 399 

stage the counts varied within the normal, but that there was a tendency 
toward a leukocytosis. In the acute stage, in every case except one in 
which leukopenia existed, there was a marked leukocytosis, in several 
instances reaching as high as 30,000. In addition to this increase in 
the white-cell count they found a constant increase in the polymorpho- 
nuclears of 10 to 15 per cent, and a diminution of lymphocytes of 15 to 
20 per cent. The other white cells showed no abnormalities. In 
view of these findings a definite leukocytosis with an increase in the 
polymorphonuclears and a corresponding diminution of the lympho- 
cytes is additional evidence, when considered with other available 
signs, in favor of the disease in question. 

Eosinophilia. — Asthma. — In true bronchial asthma the eosinophiles 
may be from 10 to 20 per cent. Cases are reported with eosinophilia 
as high as 50 per cent. Holt gives 10.7 per cent, as the average in a 
series of cases examined in his clinics by Wile ; the highest was 26 per 
cent. The presence of an eosinophilia serves to distinguish the attack 
from one of acute bronchitis or tuberculosis. The occurrence of an 
increase in the eosinophiles apparently determines the asthmatic char- 
acter in certain spasmodic attacks of the respiratory system in infancy. 

Eczema. — There is no difference between the number of eosino- 
philes in infancy and childhood and that in adult life. Occasionally 
an eosinophilia is noted in pemphigus. 

Parasites. — Any parasite, from the harmless pinworm to the most 
mahgnant uncinaria, may cause eosinophilia. It is not always present, 
nor does its degree bear any relation to the severity of the infection or 
the danger of the parasite. The presence of an eosinophilia in a child 
should always make one suspicious of intestinal worms. Amberg, in 
amebic dysentery of children, found a slight increase in the eosinophile 
count. The average number of these cells in parasitic diseases is from 
4 to 10 per cent, of the total white-cell count, but these figures may be 
exceeded. In not a few cases symptoms of pernicious anemia have 
been present, and a severe grade of secondary anemia may exist. 

In a recent case of trichinosis the eosinophile count was 72 per cent. 

Syphilis (Congenital). — There is usually a relative increase in the 
mononuclear cells and a severe secondary anemia, while a case with a 
severe rash, especially involving the face, may develop an eosinophilia 
as high as 23 per cent., diminishing as the condition improves. 

Gastro-enteritis. — In this disease there is usuallj^ no leukocytosis 
although in some cases a slight increase may be noted. It is remark- 
able that even in long-standing cases of gastro-enteritis, enterocolitis, 
etc., there is not a great reduction in hemoglobin. 

In Finkelstein 's ''Food Intoxication" one of the cardinal signs is a 
leukocytosis of from 20,000 to 40,000, the largest cell percentage being 
of the polymorphonuclear variety. 

Infectious Diseases. — Whooping-cough. — In this disease the leu- 
kocytes are increased to three or four times the normal amount, averag- 
ing 40,000 (Emerson). The change is more pronounced the younger 
the child. The early appearance of a leukocytosis is important in 



400 THE PRACTICE OF PEDIATRICS 

diagnosis. The increase is chiefly in the lymphocytes, which may 
constitute from 60 to 80 per cent, of the total white count. 

According to Frohlich and Muenier, the leukocytosis of pertussis 
far exceeds that of any other afebrile disease of the respiratory tract. 
The leukocytosis occurs in the early part of the convulsive stage, dis- 
appears with improvement, and does not seem to be influenced by 
complications. 

Measles. — Hecker (Zeitschrift fiir Kinderheilkunde) records the 
results of his blood examination of 14 children. In the incubation 
period his observations were uniform, and he concluded that during the 
incubation period, and occasionally extending into the eruptive period, 
there existed — (1) a leukopenia; (2) a relative lymphocytosis; (3) 
reduction in the number of eosinophiles. In 13 cases in the prodromal 
period Platinger found a neutrophile hyperleukocytosis of even 20,000, 
which rapidly gave place to a hypoleukocytosis during the eruptive 
stage. Holt states that there is a leukocytosis of 15,000 to 30,000, 
beginning soon after infection and increasing for four or five days. A 
marked increase in the leukocytes during the illness usually points to a 
complication. Hektoen, in his animal experimentation and observa- 
tion on human beings, found that there was a preliminary leukocytosis, 
followed by a leukopenia, chiefly of the polymorphonuclear neutro- 
philes, the lymphocytes being relatively increased. 

Diphtheria. — In this disease there is a moderate anemia, a loss of 
about 2,000,000 red cells at the time of defervescence (Emerson, 
Ewing). The reduction in the hemoglobin is usually proportionate to 
the reduction in the red cells. There is usually a slight leukocytosis, 
ranging, as a rule, from 10,000 to 15,000, but in severe cases the white 
cells may number 17,000 and with complications, 30,000 (Emerson). 
The rise is in the polymorphonuclear cells. According to Engel, the 
myelocytes are increased, especially in the fatal cases, from 3 to 16 per 
cent. Morse says, " The examination of the blood in diphtheria is of 
no practical clinical importance in diagnosis, prognosis, or treatment." 

Scarlet Fever. — Scarlet fever produces little change in the red blood- 
cells, but does cause a slight anemia (Reckzan), the average drop being 
1,000,000. There is uniformly a leukocytosis, beginning in the incu- 
bation period and continuing into convalescence (Emerson). The 
leukocytes vary from 10,000 to 40,000; in mild cases from 10,000 to 
20,000; in moderate cases from 20,000 to 30,000; in severe cases from 
30,000 to 40,000, while Holt states the number may be as high as 75,000. 
The variation is according to the severity of the case. The increase is 
chiefly in the polymorphonuclear cells, which may constitute 85 to 98 
per cent, of the total count, especially in severe and sometimes fatal 
cases. At first there is a complete disappearance of the eosinophile 
cells, and, later, a rapid increase (20 per cent.). The disappearance of 
the eosinophile cells during the course of the disease is a bad prognos- 
tic sign, and absence of leukocytosis is also ominous. 

In the Centralblatt fiir Bakteriologie of November, 1911, Dohle 
reported, in 30 cases of scarlet fever, certain inclusion bodies found 



BLOOD-PRESSURE IN CHILDREN 401 

chiefly in the leukocytes. More recent work by Nicoll, of New York, 
and Kolmer, of Philadelphia, has shown that these bodies are present 
in streptococcus infections, and the latter reports their presence in 42 
per cent, of diphtheria cases. The inclusion bodies are present in 94 
per cent. (Kolmer) of scarlet-fever cases during the first three days; 
after this they diminish in number, and are generally absent after the 
ninth day. Thus, while their diagnostic value is necessarily limited, 
their presence may be useful in the differential diagnosis of scarlet fever, 
rotheln, measles, and gastro-intestinal rashes. 

Congenital Heart Disease. — Of congenital affections, this disease 
presents the largest number of cases of polycythemia, although, as 
Osier states, *' polycythemia is not a constant feature in congenital 
cj^anosis. It is characteristic rather of the later stages of the disease, 
and its appearance is said to be of unfavorable prognosis." Vaquez 
and Quiserne state their belief that when the polycythemia reaches 
6,000,000, it seems to be fatally progressive, evidencing a more and more 
insufficient aeration, the prognosis becoming correspondingly graver. 
The red cells frequently reach 6,000,000 to 7,000,000, and the percent- 
age of hemoglobin may be as high as 160, and the specific gravity 1070; 
naturally the blood-clot is greatly increased, owing to the excess of red 
blood-cells. Cautley reports a case of polycythemia of 10,000,000, and 
Still one of 9,280,000. The white blood-cells are not increased. 

BLOOD-PRESSURE IN CHILDREN 

During the past few years numerous observations of the blood- 
pressure in different diseases have been made by Rolleston, Sergeant, 
and Hutinel, abroad, and by Howland and Hoobler in America. 

Probably the simplest and most easily handled machine of the Riva 
Rocci type is the Faught, with a cuff made from an ordinary Vorhees 
uterine dilating bag. With this combination, the smallest arm can 
be readily accommodated. An exact estimation of the pressure is not 
always possible on account of the small size of the radial artery and the 
overlying thick pad of fat, which makes palpation rather difficult, and 
especially so when the infant struggles, as is not infrequently the case. 
The Faught instrument gives readings usually from 5 to 10 mm. higher 
than other sphygmomanometers, and in practically every instance the 
personal equation is an important factor. 

Hoobler, of New York, has recently improved upon the pith-ball 
arrangement, so that it automatically and visibly indicates both sys- 
tolic and diastolic pressure, thus enabling one to eliminate variations 
due to the personal equation, which different observers have shown to 
be considerable. 

According to Kolossowa, Oppenheimer, and Bauchwitz, the follow- 
ing figures may be considered normal: 

Age, Mm. of 

Years Mercxjrt 

1-2 75-85 

3-4 85 

5-7 90-95 

8-10 95-100 

11-13 100-110 

26 



402 THE PRACTICE OF PEDIATRICS 

All febrile diseases tend to lower the blood-pressure. During the 
past few years, Comby, Hutinel, and Rolleston have found a constant 
hypotension in scarlet fever and diphtheria, more pronounced in the 
former. These authors consider a severe degree of hypotension to be 
of bad omen, especially in scarlet fever, and they believe that this con- 
dition should be met by the exhibition of adrenalin hypodermically. 

Among other causes of hypotension, Janeway enumerates 
hemorrhage, collapse, and the action of poisonous drugs, especially 
chloroform. 

Howland and Hoobler, in a series of observations, found that fresh 
air in pneumonia tended to raise the blood-pressure, and that removal 
of the patient to room temperature produced a corresponding fall. 
This rise in pressure was apparently beneJBcial in every case. The 
blood-pressure changes were not so pronounced in those convalescing 
from the disease. The value of blood-pressure estimation in epidemic 
meningitis during intraspinal injections of serum will be referred to 
later. 

Increased blood-pressure is furthermore observed in conditions of 
acute cerebral compression and anemia and in acute nephritis com- 
plicated by uremia. 

COAGULATION TIME 

The great diversity of opinion on the normal coagulation time and 
also in various diseases has no doubt been due to the variety of instru- 
ments employed ; however, the best results obtained have been those of 
Rudolf — 8.1 minutes — and Carpenter — 9.5 minutes — working with 
different instruments. 

Owing to these wide variations, despite careful technic and regula- 
tion of apparatus, no constant results have been obtained. From a 
rather exhaustive study Carpenter and Gittings conclude that it is 
improbable that any important variation exists in the coagulation of 
the blood in diseases other than those of the so-called hemorrhagic 
type. This opinion may be qualified by the statement that average 
differences of one, two, or three minutes can hardly be construed as 
of any practical importance, inasmuch as a difference of from five 
to twelve minutes has been found in typhoid fever by authoritative 
observers. 

ANEMIA 

Simple anemia is usually a secondary condition, and is not at all in- 
frequent in children. A vast majority of the cases coming under my 
observation are those of children of the runabout age, and older chil- 
dren who are suffering from tardy malnutrition, having been badly fed 
and having wasted their energy in different ways. Simple anemia may 
be the result of hemorrhage, as in hemorrhagic disease in the newly 
born and in purpura, particularly purpura fulminans (Henoch's). In 



ANEMIA 403 

the average case of anemia in my own work the hemoglobin ranges from 
40 to 50 per cent., and the red cells from 3,500,000 to 4,000,000. 
Children suffering from tuberculosis and syphilis usually show a secon- 
dary anemia. It is also temporarily present after pneumonia, scarlet 
fever, diphtheria, and typhoid fever, and similar diseases which have 
severely taxed the organism. 

I have seen a great many cases in runabout children under three 
years of age, for whom the milk diet had been continued as the almost 
exclusive means of nourishment. Children of the poor, because of the 
defective feeding and housing, are frequent sufferers. 

Symptoms. — The chief symptom is that of weakness. The appe- 
tite is usually indifferent, and the bowels are constipated. Such 
children tire readily, and are unable to keep up with their fellows at 
play or in school. They sleep poorly, and, as a rule, are irritable and 
unhappy. In appearance they are apt to be pale and thin, although 
this is not invariably the case, as I have repeatedly seen severe anemia 
in plump children. 

Illustrative Case. — A very pronounced case coming under my care was that 
of a boy of six years who weighed 4634 pounds. The blood examination showed: 
hemoglobin, 18 per cent.; red cells, 660,000. In two weeks the hemoglobin was 
20 per cent.; the red cells, 640,000. Five weeks after first examination, the hemo- 
globin was 30 per cent.; red cells, 1,172,000. The blood examination was checked 
up by a second person. No further improvement had taken place after one year 
of treatment. It was impossible to raise the blood above 30 per cent, hemoglobin 
and 1,500,000 red cells. 

Anemic murmurs ma}^ be heard over the heart, but this has been 
unusual in my cases. In the case referred to, the heart-sounds were 
normal. The spleen is not often found enlarged. 

Examination of the blood in this disease (or symptom) enables one 
to estimate with accuracy the severity of the process. In mild cases 
there may be only a reduction in hemoglobin, and the blood may 
assume the chlorotic type. There is, in addition, a reduction in the 
specific gravity, depending on the degree of anemia, and if the primary 
affection, like pneumonia, causes an increase in the leukocytes, there 
will be a leukocj^tosis. In the cases of moderate severity the red cells 
may range between 3,500,000 and 4,000,000, and the hemoglobin 
from 40 to 60 per cent. In severe cases the red cells vary from 
2,000,000, or a little less, to 3,000,000. There is a corresponding re- 
duction in the hemoglobin. The more marked the reduction in red 
cells and hemoglobin, the more marked will be the poikilocytosis and 
polychromatophilia, and the greater the number of normoblasts and 
megaloblasts. In the severe cases myelocytes may be present. There 
is no increase in the eosinophile cells. In the severe secondary anemias, 
the physical characteristics of the blood are very striking. It may be 
so thin as to separate on puncture into a reddish and a colorless portion, 
resembling beef- water (Koplik). 

The prognosis is good in the cases in which syphilis and tuberculosis 
are absent. In fact, the greater majority of the cases respond most 
satisfactorily to properly directed treatment. 



404 



THE PRACTICE OF PEDIATRICS 



Treatment. — The management consists in placing the child in a 
normal child's environment, which includes the giving of suitable food. 
The treatment described under Tardy Malnutrition (p. 100) covers 
these cases. 

In pronounced cases transfusion offers the most prompt results. 

Management of Secondary Anemia through Blood Transfusion by the 
Lindemann Me^/iod.— Signally satisfactory results have been obtained by 
this method of treatment. Infants with hemoglobin under 25 per 
cent. (Dare) and red cells under 2,500,000 have been permanently 
cured by one transfusion. So satisfactory have been my results 
that I now employ transfusion in all cases that fail to make a reason- 
ably satisfactory response to other measures. 

The following table gives in a concise manner the results of trans- 
fusion in 8 cases: 







Blood before Transfusion 


Blood after Transfusion 




1 


i 

s 

< 




1 




.1 


1 

3 
O 


c 

I 
I 




1 

1 


u 




5 

'33 








Sahli 








Sahli 






Fleischl 




F 


12 


12.5 


14 


2,400,000 


175 


24 


45 


5,120,000 


17 


70 


4,000,000 


26.8 








Sahli 








Sahli 






Fleischl 






F 


18 


24.0 


37 


3,900,000 


200 


24 


55 


5,760,000 


14 


90 


5,000,000 


32.0 








Sahli 








Sahli 






Dare 






xM 


12 


16.4 


32 


4,480,000 


300 


24 


78 


5,150,000 


3 


60 


3,840,000 


19.5 




















6 


52 


4,400,000 1 22. 2 




















12 


63 


5,000,000|25.5 




















18 


65 


5,000,000 


28.0 








Sahli 






Sahli 






Dare 




F 


23 


15.10 


20 


2,800,000 


140 


24 


55 


3,100,000 


1 


37 


2,700,000 16.7 




24 


16.7 


30 




200 


24 


90 


4,320,000 


7 




19.8 








Sahli 








Sahli 






Dare 


1 


F 


G 


11.0 


37 


1.600,000 


150 


24 


85 


4,000,000 


7 


65 


4,800,000 


19.5 








Dare 








Dare 






Dare 




M 


10 


12.5 


33 


4,300,000 


200 


24 


58 


4,900,000 


1 


58 
Died of 
later, 
mal, g 
good. 


5,000,000il2.8 
meningitis, 3 mo. 
Blood count nor- 
eneral condition 








Sahli 








Sahli 






Dare 


1 


F 


12 


12.4 


35 


3,120,000 


170 


24 


62 


4,040,000 


1 
3 


50 
50 


5.320,000jl4.0 
4,100,000!l7.4 




















6 


56 


4,400,000 


19.8 








Sahli 




. 




Sahli 






Dare 






M 


16 


21.0 


35 


3,300,000 


200 


24 


55 


3,400,000 


1 


60 


4,500,000 


24.8 






Fleischl 


















. 






6 


55 


4,100,000 25.12 

1 



CHLOROSIS 405 

CHLOROSIS 

Chlorosis is a form of anemia most frequently seen in young girls at 
the time of puberty or later. The cause of the condition is not known. 
Various theories have been advanced, none of which can be proved. 
The most plausible theory assumes the existence of a persistent intes- 
tinal intoxication. That such is a probable cause has been suggested in 
my cases. The more pronounced changes occur in the specific gravity 
of the blood, and correspondingly in the hemoglobin, both of which are 
reduced out of proportion to the reduction in red cells, although in 
severe cases the red-cell count may fall to 1,000,000. In ordinary cases 
the corpuscles vary between 3,000,000 and 4,500,000, while the 
hemoglobin may be as low as 30 per cent. There is no leukocytosis, 
but microcytosis, poikilocytosis, and polychromatophilia are usually 
present. 

Symptoms. — The symptoms are quite characteristic. The patient 
is habitually tired and incapable of unusual or prolonged exertion. 
The skin is of a peculiar sallow, greenish color. The hands and the feet 
are cold. Amenorrhea is almost always noted in girls who have passed 
the period of puberty. I have known the menses to be discontinued for 
a year. The appetite is capricious, and the patient craves most un- 
suitable articles of food and substances not in the food class. The 
history usually includes the story of habitual constipation which was 
never treated. 

Anemic heart murmurs and the venous hum over the vessels of the 
neck are usually present. The patient is nervous, irritable, and not in- 
frequently hysteric. I have seen one pronounced case of hystero- 
catalepsy in a young girl with chlorosis. 

Prognosis. — While this condition is usually obstinate, the outcome 
in my cases has always been favorable. 

Treatment. — The management consists in the correction of the con- 
stipation and in the provision of suitable food at definite intervals. 
Eating between meals must not be allowed. Stress, both physical and 
mental, is to be avoided. Iron and arsenic are of value. The follow- 
ing combination of drugs has served me well: 

I^ Strychninse sulphatis gr. 34 

Acidi arsenosi gr. H 

Extract! ferri pomati gr. vj 

Extract! cascarae sagradse gr. xxx 

Ch!niae bisulphatis gr. Ix 

M. ft. capsular no. xxx. 

Sig. — One after meals. 

The amount of cascara prescribed depends upon the degree of 
constipation. 

After the diet and the bowel habit have been satisfactorily adjusted, 
the patient should be given a change of environment. I know of 
nothing so conducive to a reasonably prompt cure as an absolute 
change in the daily life of the patient. 

Entertainment and amusements which do not excite or overtax are 



406 THE PRACTICE OF PEDIATRICS 

to be encouraged. The cure will be aided by removal of the patient 
from the association of persons who are not congenial. 

PSEUDOLEUKEMIC ANEMIA OF VON JAKSCH 

In this affection there is marked anemia with enlargement of the 
spleen. The condition was first described by von Jaksch, who believed 
it to be a clinical entity. The disease represents an unusually severe 
type of secondary anemia, and is of toxic origin, the nature of which is 
not understood. 

There are no valid grounds for believing so rare a disease to be 
dependent upon rachitis or syphilis. Syphilis and rachitis occur with 
the greatest frequency. If these diseases were causative factors, it is 
reasonable to suppose that there would be many more cases. The 
great majority of the cases follow prolonged intestinal disturbance and 
malnutrition. 

Pathology. — The pathologic changes comprise enlargement of the 
spleen and moderate swelling of the lymph-nodes, with a diminution in 
the specific gravity, the hemoglobin, and the number of red cells in the 
blood, and an increase in the leukocytes. 

The Blood. — The number of red cells is frequently as low as 
2,000,000. It may fall to 800,000. The color index is low. The 
hemoglobin reduction is very great, and may reach 30 per cent. 
(Emerson, Comby, Cautley). There is always a leukocytosis of from 
20,000 to 50,000. In one case reported by Emerson the leukocytes 
numbered 114,000, and in another, at the Babies' Hospital, 96,000. 
They may show an increase in the mononuclear or polynuclear 
forms. The eosinophiles are usually increased, but may be normal or 
diminished. The white cells exhibit great variety in size, shape, 
and staining properties. Mast cells and myelocytes in small numbers 
may be found. Karyokinesis is common, and is regarded by some 
observers as of diagnostic importance (Comby). The red cells include 
many microcytes, myelocytes, normoblasts, and megaloblasts, and 
show, in addition, poikilocytosis and polychromatophilia. 

Symptoms. — The symptoms are those of progressive, pronounced 
anemia in a child usually well nourished. Emaciation may develop 
later in the disease. The patient becomes very weak and his activities 
cease. 

The appetite is often greatly impaired, and food, if urged, is apt to 
be vomited. In the later stages hemorrhages from the mucous surfaces 
may occur. Petechise are common. The lymph-nodes show moderate 
enlargement. 

Fever is occasionally present, usually due to intestinal conditions. 

Probably the best recent discussion of this condition is that of 
Cabot, who thinks that the many very different cases thus diagnosed 
cannot be grouped together. 

Prognosis. — The prognosis is very unfavorable. Death in the 
fatal cases take place from intercurrent disease. Patients who exhibit 
improvement for a time usually succumb later. 



LEUKEMIA 407 

Treatment. — The management is entirely supportive. Iron and 
arsenic may be given in the hope that they will be of some benefit. 

LEUKEMIA 

Leukemia is a disease marked by the cons ant presence in the blood 
of granular mononuclears, or an increase in the blood of the non-granu- 
lar cells with round nuclei — the miniature cells of the blood-building 
organs, which are not normally present in the peripheral circulation. 
There is also a decided change in the blood formula. Generally there is 
a marked increase in the leukocytes, and yet there are instances when 
the count is normal and the diagnosis is made from the increase of ab- 
normal cells. 

Splenomyelogenous Leukemia. — In this disease there is a great in- 
crease in the granular cells, more especially the myelocytes, eosino- 
philes, and basophiles, and also in the cells with spheric or slightly 
indented nuclei (Emerson). The total blood is increased in the ma- 
jority of instances and diminished in few. In a great many cases the 
blood may appear to the eye normal ; in extreme cases it is pale, 
opaque, and flows sluggishly. 

The red cells are greatly reduced in number — occasionally as low as 
2,000,000. Poikilocytosis is present in all cases; microcytosis and 
macrocytosis are rare, while polychromatophilia is usually present. 

This is the condition par excellence in which normoblasts are 
present in abundance. In many cases megaloblasts are found. The 
hemoglobin is much reduced. 

The white cells vary from 100,000 to 500,000 (Holt), or, as men- 
tioned before, may be normal in number. Neutrophiles are absolutely 
diminished, but relatively increased. The lymphocytes are increased, 
but vary according to the stage of the disease. Eosinophile myelocytes 
are found, and there is an absolute increase in the eosinophiles. Ehr- 
lich states that in this disease there is always an increase in the baso- 
philes and Cornil's myelocytes are present. 

Lymphatic Leukemia. — In the lymphatic type there is a marked 
increase in the mononuclears. Despite the name, the increase is not 
always in the lymphocytes, although this increase is most usually in the 
small mononuclears, which in some cases have been known to form 
97 per cent, of the total white cells. Polymorphonuclears are rare. 
Eosinophile cells are noticeably absent, and in a pure case myelocytes 
are not present. There is a greater anemia in this form than in 
splenomyelogenous leukemia. 

In a review by Churchill (1904) the lowest red-cell count reported 
was 750,000 after a severe hemorrhage, and the leukocytes varied from 
6000 to 810,000 (in a twenty-months'-old child). In a case reported 
by Wollstein from personal observation there were 99 per cent, of 
small mononuclears, many of which were degenerated. 

Etiology of Leukemia. — ^Leukemia is rare in childhood. Its cause 
is unknown. 



408 THE PRACTICE OF PEDIATRICS 

Morbid Anatomy. — The bone-marrow is always changed; in acute 
lymphatic leukemia it is red or gray, with an increase mostly in the 
lymphocytes. In myelogenous leukemia the marrow is red, grayish 
white, or greenish, with an increase in the myelocytes. 

The spleen is enlarged in all forms of leukemia, and may be enormous 
in size. 

Adenoid tissue throughout the body is hyperplastic. 

The liver is enlarged, and contains many small grayish or yel- 
lowish areas which are collections of leukocytes. 

The lymph-nodes are always enlarged in lymphatic leukemia, and 
may be enlarged also in the myelogenous form. The cervical, axillary, 
and inguinal nodes may form masses as large as an egg or even larger. 
These masses are soft, painless, and not adherent to the skin. 

Leukemic infiltrates or lymphomata, circumscribed or diffuse, con- 
sisting of masses of lymphocytes, may be present in the kidneys, 
lungs, skin, peritoneum, dura, myocardium, pancreas, etc. 

Illustrative Case. — A boy, four years of age, weighing 33 pounds, was referred to 
me by Dr. Brooke, of Bayonne, N. J. For nine months there had been a gradual 
abdominal enlargement, with pallor and gradually increasing weakness. The 
spleen was enormously enlarged, extending 1 inch above the pubes and 1^ inches 
to the right of the umbilicus. Examination of the blood showed: Hemoglobin, 35 
per cent.; red blood-cells, 2,000,000; white blood-cells, 760,000; myelocytes, 61 
per cent.; polynuclears, 41 per cent.; lymphocytes, 10 per cent. Benzol, in two 
minim doses (in emulsion), three times daily, was given for six weeks, at which time 
the boy showed marked improvement. The appetite was much better. He was 
more active. The general appearance was decidedly better. The spleen had ap- 
preciably decreased in size. The blood examination showed that the general 
betterment was consistent: Hemoglobin, 48 per cent.; red blood-cells, 3,728,000; 
white blood-cells, 272,000; myelocytes, 27 per cent. After three months the child 
failed rapidly and died in another city without later blood examination. 

Prognosis. — The prognosis is most unfavorable. Few patients sur- 
vive one year of the disease. Reported recoveries probably mean er- 
rors in diagnosis. Death usually takes place from intercurrent disease. 

Treatment. — Nutritional measures should be brought into use. 
Iron, arsenic, and cod-liver oil are usually employed. Dr. Frank 
Billings, of Chicago, reports benefit in five adult cases treated with 
benzol. My own observation with benzol has been as unfavorable 
as other methods of treatment. 



PERNICIOUS ANEMIA 

Pernicious anemia in infants and young children is very rarely 
seen. In fact, its existence in children has been questioned, for blood 
states described as peculiar to pernicious anemia have been found in 
other diseases, as in rachitis and syphilis, in which there is extreme 
anemia. On the other hand, cases of primary pernicious anemia 
have been reported by observers of repute sufficiently often to establish 
the disease as an entity. 

Lesions. — In pernicious anemia there is extreme general pallor, 
and fatty degenerations of the heart muscle, the liver, the pancreas, 



PURPURA 409 

the gastro-intestinal epithelium, and the kidneys. In addition, 
hemosiderosis is present in the Hver, spleen, bone-marrow, and kidneys 
due to the destruction of red blood-cells. Capillary hemorrhages 
into the viscera are rarely lacking, and are especially frequent in the 
nervous structures and in the serous membranes. The color of the 
bone-marrow may be changed from yellow to red, and microscop- 
ically shows many megaloblasts. 

The Blood. — The specific gravity and coagulability are much re- 
duced, and the hemoglobin may be low as 20 per cent. In the fresh 
specimen, rouleaux formation is absent, and the cells vary much in size 
and shape, extreme poikilocytosis being the rule. A large increase in 
the megalocytes, with absence of microcytes, is very suggestive of the 
disease in question. Owing to the relatively high content of hemo- 
globin, the red cells stain fairly well and uniformly, but in many cases 
there is a degeneration with accumulation of hemoglobin in the center 
of the cell. The megaloblasts usually outnumber the normoblasts. 

In severe and uncomplicated cases there is always a leukopenia, 
and the polymorphonuclear count is roughly parallel to the leukocyte 
count. Myelocytes are usually present. 

Symptoms. — The symptoms are those of rapidly progressive, high- 
grade anemia. The chief symptoms are pallor and marked exhaustion. 
The patient is intensely prostrated, and gastro-intestinal crisis de- 
velops. Emaciation is not of constant occurrence. Petechise and 
submucous hemorrhages occur. The duration of the disease is but 
a few months, and the true cases are fatal. 

PURPURA 

By purpura is understood a condition in which the blood either 
escapes from its natural channels and constitutes a hemorrhage, or 
becomes localized in different portions of the skin and subcutaneous 
tissue, with no constant change in its character or demonstrable lesion 
in the vascular walls. 

Simple Purpura. — Simple purpura occurs in the form of petechise, 
often as a terminal symptom in exhausting diseases. It may result 
from severe vascular strain, as in pertussis. I have seen several such 
cases. Purpura is a prominent symptom in scorbutus and peliosis 
rheumatica. It may occur as a direct effect of poisonous drugs. Thus 
in my own cases it has resulted from accidental large dosage of phos- 
phorus and antipyrin. In a vast majority, if not all, of the cases, 
the condition is due to toxic agencies originating within the body or 
introduced from without. 

The Hemorrhagic Type. — The distinction between simple and hem- 
orrhagic purpura is largely one of degree. In the hemorrhagic type 
there are free hemorrhages from different portions of the body, usually 
associated with extensive subcutaneous hemorrhage or hemorrhages 
into different organs. Massive hemorrhages have been designated 
as purpura f ulminans, or Henoch 's purpura, and here again the differ- 



410 THE PRACTICE OF PEDIATRICS 

entiation is based upon the severity of the condition and involves an 
unnecessary classification. 

The hemorrhage and its persistence depend upon the nature of the 
infection and the resistance of the individual. 

Illustrative Cases. — One of my patients, two years of age, developed a mild 
purpura while taking large doses of antipyrin, which was being administered 
as the result of a misunderstanding. In pyemia, purpura is not unusual. In a 
patient nineteen months of age, who died from a septic sinus thrombosis with 
extension to the jugulars, there was extensive purpura for forty-eight hours before 
death. Blood examinations made from this patient during life showed pure cul- 
tures of streptococci. Another patient, a boy eight years of age, previously 
healthy, died in three days from purpura fulminans (Henoch). Death resulted 
from extensive hemorrhages under the skin, combined with hemorrhages from the 
nose, mouth, and intestines, and presumably the viscera. An autopsy was not 
allowed. In this case also blood cultures made postmortem, from subcutaneous 
hemorrhagic areas, showed pure growth of streptococci. 

A notable case was that of a boy seen in consultation with Dr. Corwin, of 
Rye, N. Y. The family history was negative. The tonsils and adenoids were 
removed six months before the illness, without more than the usual bleeding. 
Two months before the illness the boy fell and broke off an incisor tooth. No 
bleeding followed the accident. On June 15, 1910, the patient was taken ill with 
tonsillitis. The temperature ranged from 100° to 102°F., and continued for one 
week. During this time numerous subcutaneous hemorrhages appeared at vari- 
ous sites over the body, particularly on the leg. A large hematoma developed in 
the abdominal wall. There was some bleeding from the gums, and the subcutane- 
ous hemorrhages continued to appear on the chest, abdomen, and legs. There 
was moderate bleeding from a biscuspid tooth. The child was given calcium 
lactate in small doses, three grains every three hours. The hemorrhage from the 
gum stopped, and the subcutaneous hemorrhages began to show signs of absorption. 

On July 7th, a little over two weeks after the first sign of the purpura, there was 
a hemorrhage from the nose which lasted about an hour. On the following day 
there was another hemorrhage from the nose which lasted five hours, resisting all 
ordinary methods of control. The patient was at this time seen by me. He 
evidently had suffered much from loss of blood. The eyes were sunken and the 
skin was pale and sallow and showed in many areas the evidences of the previous 
subcutaneous hemorrhage. The child was markedly prostrated . Calcium lactate 
was resumed in 10-grain doses every two hours. On account of the greatly reduced 
condition of the patient, normal salt solution was given by the drop rnethod through 
the tube introduced into the colon. The stools at this time* consisted largely of 
coagulated blood. 

July 9th the hemorrhage appeared to be controlled. Twenty grains of calcium 
lactate were given every two hours. 

July 10th nasal hemorrhage began at 5 a. m. and continued for five hours. 
Saline irrigation returned blood-stained. The child was now in an extreme con- 
dition, and 30 c.c. of the human serum were injected subcutaneously by Dr. J. E. 
Welch. During the remainder of the day from 45 to 60 c.c. of the human blood- 
serum were injected at two-hour intervals until midnight. The amount injected 
in twelve hours was 290 c.c. In the evening there was an evacuation of the bowels, 
composed entirely of coagulated blood. 

July 11th the stools contained blood, and the expectoration contained some 
bright red blood. There was a moderate nasal hemorrhage. At 8 a. m., 3 p. m., 
and 9 p. m., 167 c.c. of human blood-serum were given in three doses. 

July 12th there was no visible hemorrhage from any portion of the body. 
Four injections of the blood-serum were used, the total amount being 191 c.c. 

July 13th, 14th, and 15th three injections of the blood-serum were given at 
about six-hour intervals, in quantities ranging from 20 to 30 c.c. 

July 16th two injections of the serum were given, at twelve-hour intervals, — 
44 c.c. in all, — and on July 17th one injection of 35 c.c. was given. The total 
amount of serum given during the one week of treatment was 1034 c.c. 

From this time the child manifested a slow but steady improvement, and even- 
tually made a perfect recovery. It was of interest to note that the hemorrhage, 
which had continued intermittently for nearly three weeks, ceased within fifteen 
hours after the first injection of human serum. While the treatment with the 



HEMOPHILIA (bleeder's DISEASE) 411 

serum was being carried on the child was kept alive by predigested foods and free 
stimulation. For obvious reasons, a blood culture was not made. Without 
doubt there was a bacteremia with resulting blood changes which the human serum 
was able to control. 

In the two years that have intervened there has been no hemorrhage nor any 
suggestion of bleeding from any portion of the body. 

Apparently here was a case in which, beyond all possibilities of doubt, the use of 
the human blood-serum saved the life of the child. 

Prognosis. — The prognosis in the simple cases is good. The phos- 
phorus-poisoning case was fatal, but not alone owing to the hemor- 
rhage. In hemorrhagic cases of severe type the outcome appears to 
depend upon the promptness with which human serum is introduced 
into the circulation. The appearance of purpura in serious or pro- 
longed diseases is a very unfavorable sign. 

Treatment. — The treatment of the milder cases is that of the dis- 
ease with which the purpura is associated. An effort should be made 
to establish the vitality and resistance of the patient by removal, 
when possible, of the cause of the condition, and by the administra- 
tion of acids and fruit-juices. The use of ergot and suprarenal extract 
has not been of appreciable service. Calcium lactate has appeared to 
be of some value in cases not severe. Twenty grains should be given 
every two hours. 

Serum Treatment. — As a means of prompt relief, human blood- 
serum far exceeds in value all other agents. It may be used as in- 
dicated in the case referred to. From 2 to 4 ounces should be given 
daity until the hemorrhage is controlled. (See Hemorrhagic Diseases 
of the Newly Born, p. 157.) 

HEMOPHILIA. (BLEEDER'S DISEASE) 

By ''hemophilia" is meant a constitutional tendency to uncontroll- 
able bleeding, spontaneous or arising from wounds which in the normal 
individual occasion little or no bleeding at all. 

Etiology. — Isolated cases of hemophilia are not unknown but there 
is no doubt that the family histories of these patients are defective. 
It is more usually the case that the bleeding tendency is known in the 
family, and that one or more of the child 's ancestors has suffered from 
the complaint, or, where a ''bleeder" has been born of healthy parents 
that one or more of the succeeding generations is affected. 

The peculiarity^ of this condition lies in the mode of inheritance; 
the males of the family alone are affected, while the tendency is trans- 
mitted through the females. This law up to the present time has no 
authentic exception according to the careful researches of Bullock and 
Fildes. This mode of inheritance is not unique for there is evidence 
that cases of partial albinism follow the same law (Nettleship) and it 
has also been observed in certain cases of color-blindness and night- 
bUndness. It has been suggested that these and other instances are 
examples which can be best explained on the Alendelian theory. 

In a family of bleeders, the female members transmit the disease 
and the males manifest it. Thus, a girl whose mother is a bleeder 



412 THE PRACTICE OF PEDIATRICS 

will not show signs of the disease, but will transmit the condition 
to her children while her brother will be a bleeder himself and yet his 
children by a healthy wife, will not be bleeders, although his grand- 
sons, through his daughters, may suffer from the disease. The tend- 
ency to transmit hemophilia is no stronger in a woman from a family 
of bleeders, who herself is a bleeder, than her sister, who may not be a 
bleeder. Marriage to individuals who are not affected is no means of 
preventing the condition. It is a curious fact that the disease has 
been found in large families. 

The condition is rarely noticed at birth but in most instances is 
recognized before the end of the second year has been reached. Before 
the tenth year it is almost always fatal and after the twentieth year the 
condition is very rare. Most of the cases observed have been among 
Germans and Jews, while it is practically unknown in the tropics. 

Pathology. — In those who succumb to the disease the chief altera- 
tions are due to the draining of the blood from the organs. With this 
exception there is no constant anatomical change. There may be an 
endarteritis, fatty degeneration of the intima and thinning of the 
vessel walls making the arteries resemble the veins. 

Blood Changes. — There is usually a slight decrease in the number 
of leukocytes especially of the polymorphonuclear variety and beyond 
this the changes are but transitory. Following a severe hemorrhage 
the red cells are promptly restored to their normal number, and the 
hemoglobin much more slowly, so that a simple anemia may be present 
for weeks following a severe hemorrhage. 

The various observations recorded regarding the coagulation time 
are most conflicting and are probably due to the lack of uniformity 
of technique. Wright believes that the coagulation is much prolonged 
while Sahli considers it diminished in the interval and normal or 
increased during the height of an attack. 

Various hypotheses have been propounded to explain this abnor- 
mal tendency to hemorrhage such as abnormal fragihty of the vessel 
walls (Virchow) increased blood- pressure (Immerman) a definite in- 
fectious process (Koch) while Sahli considers it an abnormal chemical 
alteration in the walls of the blood-vessels, which results in the failure 
of a substance (thrombokinase) which is essential to the formation 
of a clot. 

Symptoms. — The first manifestations of hemophilia are not often 
seen before the second year. The hemorrhages of the newly born 
have no relation to this condition. The most significant symptom is 
bleeding of a serious nature from slight injury or no apparent cause. 
There may be a severe sudden hemorrhage, or a constant oozing of 
blood which resists all attempts to check it. Such trivial injuries as 
the extraction of a tooth or even dentition, may give rise to prolonged 
bleeding of a serious aspect but it is a curious fact that menstruation 
and childbirth, are not, as a rule accompanied by great loss of blood. 
These hemorrhages, usually of mucous membranes, take place in the 
gums, nose, throat or bowel. Effusion of blood into the joints may be 



hodgkin's disease (lymphadenoma) 413 

chronic with some hmitation of motion and even ankylosis resulting. 
Following these hemorrhages we have symptoms common to hemor- 
rhage from any cause and if it be a fatal one the patient dies from 
exhaustion. Sometimes death is preceded by, or occurs, during a 
convulsion. 

Prognosis. — The prognosis is on the whole bad in childhood. 
Fully half of the hemophilic patients die before reaching their eighth 
year and less than 12 per cent, survive to puberty (Littar v. Et- 
linger). The first manifestation rarely kills. 

Diagnosis. — The diagnosis of hemophilia must rest to a large 
extent upon a knowledge of the famil}^ history. Where there is no 
known ''bleeder" in the pedigree, the diagnosis of hemophilia is always 
open to criticism. It must be remembered that there are other causes 
of repeated and obstinate hemorrhage than hemophilia, that, for in- 
stance, in recurrent idiopathic purpura, such hemorrhages are met with, 
and that effusion into the joint cavities occur in both diseases. In 
hemophilia the effusion is bloody; in purpura it is invariably serous. 
In hemophilia according to Pratt there are about 450,000 platelets 
per cubic centimeter whereas in purpura there are 50,000 or less. 
Blood examination rules out anemias and leukemias. 

Treatment. — Prophylaxis is the most effective treatment, marriage 
should be discountenanced. Such advice, however, is rarely followed 
out as the records of the various ''bleeder" families show. The 
patient should be guarded from birth against all operations unless they 
be of a life-saving nature and then previous treatment with calcium 
lactate or thyroid should be used, while at the time of operation blood 
serum may be injected subcutaneously. 

In the event of hemorrhage styptics should be employed, the most 
effective being tannic acid or the perchloride of iron. Good results 
are obtained from the administration of calcium lactate in the dose 
of 15 grains three times daily in cases of persistent epistaxis. Gelatine 
is of little service. In cases of severe hemorrhage blood transfusion 
should be resorted to and if practicable the father's blood should be 
employed. Numerous cases are on record where this procedure has 
tided patients over critical periods. If transfusion is impossible re- 
peated injections of human serum or even animal serum may be 
employed. 

HODGKIN'S DISEASE (LYMPHADENOMA) 

The best description of this disease coming to my observation is to 
be found in the Johns Hopkins Hospital Reports, vol. x, by Dr. Reed. 

Hodgkin's disease is of extreme rarity in children. The onset is 
very gradual. The first symptoms are usually those of an enlargement 
of the glands of the neck — usually a one-sided involvement. There 
is an associated anemia, progressive in type. On account of the en- 
largement of the glands, there may be pressure, pain, cough, and ob- 
struction to respiration. The glandular enlargement may become ex- 
treme. The only changes in the blood are those of marked anemia. 



414 THE PRACTICE OF PEDIATRICS 

Lesions. — The lymph-nodes are enlarged. At first they are soft, 
gray or grayish red, moist, and show irregular areas of necrosis, 
which are very characteristic. Microscopically, eosinophils, giant- 
cells, and some plasma cells are seen. Later the glands become small 
and hard, showing, on section, a glistening, white cut surface. This is 
the stage of cicatrization ( Aschoff) . 

The spleen is enlarged, but not so markedly as in leukemia. The 
cut surface is mottled and irregular, due to red or gray masses (lym- 
phomata) in the follicles. 

There may be enlargement of all the adenoid tissue in the body, 
and lymphomata, smaller than those found in leukemia, may be present 
in the liver, lungs, kidneys. 

Treatment. — All the means used have been ineffectual in true cases. 



XI. THE GLANDULAR SYSTEM 

DISEASES OF THE LYMPHATIC GLANDS 

Lymphatic gland enlargement is of most frequent occurrence in 
children. It is quite usual, in making a physical examination in 
children, to find the postcervical and the inguinal glands slightly 
enlarged. Such enlargement is frequently of no significance. 

ACUTE CERVICAL ADENITIS 

Infants and young children possess a ready susceptibility to gland 
infection. There may be a general glandular involvement — in such 
instances the child may be in depleted condition and the glandular 
hyperplasia is of no consequence. In these cases, the glands will 
show but very slight or moderate enlargement. In pseudo-leukemia, 
leukemia and lymphatism the glands will show a vastly greater degree 
of hyperplasia, and the blood examination will determine this condition. 
In syphilis the only glandular involvement of signifiance will be found 
in the epitrochlears. 

In tuberculosis the process is always localized, usually at the angle 
of the jaw. The inguinal glands are often found enlarged in eczema, 
intertrigo and in balanitis. Pediculi of the scalp are very apt to 
produce involvement of the posterior cervical glands. 

Etiology. — In cervical adenitis the inflammation results from the 
draining of an infected source, which may be a decayed tooth, a diseased 
tonsil, a purulent rhinitis, or any focus from which bacteria may be 
transferred. In grip, tonsillitis, scarlet fever, diphtheria, measles, and 
in any throat infection, adenitis may be and frequently is a complication. 

Pathology. — The process in the gland may be a simple hyperplastic 
change, or it may reach the stage of suppuration. The microorganism 
most commonly associated with suppurative adenitis is the strepto- 
coccus, but the staphylococcus, the pneumococcus, the gonococcus, 
and the typhoid bacillus have been cultivated from diseased lymph- 
glands in various regions. 

Symptoms. — The first symptom noticed will be that of a swelling 
at the angle of the jaw (Fig. 48), hard, rounded, and quite painful to 
the touch. Preceding the enlargement there may be a period of fever 
for a day or two, during which time the child moves the head awk- 
wardly. Rarely one gland alone will be involved. Usually there are 
several, although the external examinations will make it appear that 
one, or at the most, two, are enlarged. The tumor may reach a very 
large size. I have seen the entire space between the jaw and the clav- 
icle filled in and almost replaced by these glands. 

415 



416 



THE PRACTICE OF PEDIATRICS 



The temperature is usually high. In simple adenitis with suppura- 
tion I have repeatedly seen it range from 102° to 105°F. 

Duration. — The duration varies widely. If there is a streptococcus 
.infection, suppuration may occur in a few days. In scarlet fever this 
microorganism is usually the infecting agent, a fact which accounts for 
the many suppurating glands that occur with this disease. 

Termination. — The infection always terminates in one of three 
ways: First, resolution; second, suppuration; third, persistent enlarge- 
ment (chronic adenitis). 




Fig. 48. — Cervical adenitis. 



Differential Diagnosis. — Acute adenitis and mumps are very fre- 
quently confused. By a comparison of Fig. 48 and Fig. 84 it will be 
readily seen that the two conditions have but little in common. In 
mumps the parotid gland is involved and the swelling is situated close 
to the ear, with the space posterior to the lobe filled in by that portion 
of the parotid gland. 

Prophylaxis. — -A normal, resistant throat is the best safeguard 
against cervical adenitis. Removal of adenoids and enucleation of the 



ACUTE CERVICAL ADENITIS 



417 



tonsils are better insurance against cervical gland infection than all 
other means combined. 

Axillary and Inguinal Adenitis. — In axillary and inguinal adenitis 
the infected area from which the process has its origin must be eradi- 
cated. In the inguinal cases balanitis in boys and vulvovaginitis in 
girls are frequent sources of infection. Axillary adenitis (Fig. 49) is 
very unusual. When it occurs, the infection has usually been carried 
from a lesion somewhere in the upper extremity. 

Treatment. — After treating many hundreds of cases of adenitis, I 
have been impressed with the great value of cold applications in the form 
of a cold-water compress changed every fifteen minutes to half-hour, 
day and night. Such 
treatment is arduous, 
and, of course, in many 
instances impossible, 
particularly in dealing 
with young infants. 
With older children 
the dressing may be 
changed withou 
awakening the patient 
For infants the treat 
ment may be con 
tinned with good effect 
from 14 to 16 times a 
day. The last dressing 
for the night is to be 
kept bound on the 
parts. The use of 
ointments and local 
applications other than 
cold is disappointing. 
The ice-bag is not so 
satisfactory as the wet 
compress. 

Suppurative Cases. — Even when the cold compress or ice-bag is 
applied at the first suggestion of swelling and used faithfully, the cases 
of streptococcus infection usually go on to suppuration. Repeatedly 
I have seen the adenitis, which is often an early complication of diph- 
theria, disappear quickly after full doses of diphtheria antitoxin. When 
the swelhng softens, we know that suppuration has taken place, and our 
only treatment is to incise freely, allowing the pus to escape, and place 
in the wound a strip of sterilized gauze to assist in drainage and to pre- 
vent too early closure of the incision. The wound should be dressed 
once daily. Extirpation of the diseased gland is not to be advised until 
later, if at all. In fact, a greater part of all the gland tissue may have 
undergone suppuration, producing complete destruction. 
27 




Fig. 49. — Axillary adenitis. 



418 



THE PRACTICE OF PEDIATRICS 



PERSISTENT SIMPLE ADENITIS 

After an acute adenitis, in a small percentage of cases, the gland or 
glands will remain persistently enlarged, so as to constitute a deformity. 
The deformity may likewise be the result of a series of acute attacks, 
each leaving the gland a little larger than before. Whether these 
glands are tuberculous from the outset, or become so later, it is im- 
possible to state. I know, however, from observation of many patients^ 
that some cases which do not show the distinctive characteristics of 
tuberculous adenitis which we have been taught to expect, do show 
that they are tuberculous upon examination of the glands which have 

been removed at operation 
because of the unsightly 
deformity. I have, there- 
fore, come to look upon 
pronounced persistent 
adenitis as probably of 
tuberculous origin, even 
though but two or three 
glands appear to be in- 
volved. Because these 
chronically enlarged glands 
sometimes undergo resolu- 
tion without suppuration 
does not prove the absence 
of tubercle bacilli. 

Treatment. — I have 
treated these cases of per- 
sistent adenitis with elec- 
tricity, drugs, and local 
medicinal applications, but 
am unable to advise the 
use of any one of them, nor 
have the iodids in my hands 
been of any appreciable value. The only local means of utility has 
been the more or less persistent applications of cold in the form of a 
wet compress. • The dressing is changed every half-hour — a treatment 
which is never popular, but which sometimes succeeds. At bedtime 
the tumor is massaged for fifteen minutes with any non-irritating oil. 
The Bier Hyperemia Treatment (Fig. 50). — This method of treat- 
ment consists in the application of the Bier neck band (Kny-Scheerer, 
New York) sufficiently tight to produce a slight capillary engorgement 
of the skin over the face. The band is worn for eleven hours, and kept 
off one hour. This method of treatment is of some value in the more 
acute cases, in which the glandular involvement has resisted cold 
application and promises to pass into the chronic stage. 

Constitutional means, of course, should be employed, iron, cod- 
liver oil, and the hypophosphites being prescribed, if the child's 
condition appears to require them. In many cases, however, such 




Fig. 50. — Cervical adenitis, showing Bier band 
in position (five and one-half months). 



GLANDULAR FEVER 419 

treatment is not called for, as the children are in perfect condition, the 
process being entirely local. I have had no experience with the " a::-ray " 
and various ''light" methods of treatment which are advocated by 
some writers. My own observation in the management of these cases 
has been that when the glands remain for several weeks sufficiently 
large to produce a deformity, removal by surgical means is the only 
course to pursue. The operation is simple in good hands, is quickly 
performed, and need leave but a very slight scar. 

GLANDULAR FEVER 

Glandular fever is a disease of early childhood. It is rarely seen 
in children after the fifth year. It is characterized by swelling of the 
lymph-nodes at the angle of the jaw forming an elongated tumor be- 
tween the angle of the jaw and the sterno-mastoid muscle. The tumor 
may reach a considerable size. I have seen cases in which the tumors 
were as large as hen 's eggs. Both sides are usually involved; the swell- 
ing is first noticed on one side and is usually followed by an infection 
of the glands on the opposite side. Rarely are the axillary and in- 
guinal glands affected. Fever is present, usually from 101° to 104°F., 
there is prostration and loss of appetite. 

The disease occurs most frequently in epidemic form although 
sporadic cases are not unusual. Park West* described an epidemic of 
96 cases in 43 families during a period of three years. The last large 
epidemic was described by Schaffer in 1909. A similar outbreak oc- 
curred in New York City in the Spring of 1911. During this epidemic 
I treated 30 cases in my own private practice. 

Pathology and Bacteriology. — The pathology of this affection 
is obscure. So far the evidence at hand tends to point to a streptococcus 
infection and with the improved technique of blood cultures in infants, 
an answer to this question should be forthcoming in the near future. 
Cultures from the throat have shown no uniform results but in many 
instances streptococci have been found in the pus either at autopsy 
or operation. Korsakoff found streptococci in pure culture in the 
cervical and axillary glands, liver, spleen, kidneys and heart's blood, 
while in the same case the glands showed an acute hyperplastic change 
with dilated blood-vessels. In reports of cases, blood cultures during 
life are not mentioned. 

Differential Diagnosis. — This disease is to be differentiated from 
mumps in that the parotid glands are not involved, and from acute 
simple adenitis by the absence of throat involvement and by the fact 
that nearly all cases recover without suppuration or resulting per- 
sistent adenitis. In several of the cases seen during a recent epidemic 
the rhino-pharynx was normal. Two or more children in a family 
may have the disease at the same time. 

Treatment. — The treatment consists in the continuous use of 
ice-bags or the cold compress (p. 283) and laxatives such as milk 
* Arch, of Pediatrics, 1896. 



420 THE PRACTICE OF PEDIATRICS 

of magnesia, sufficient to produce one or two evacuations daily, a 
reduced diet of broths and gruels, and keeping the patient in bed. 
The swelling may last from five days to two weeks, and in my cases has 
subsided without suppuration. 

TUBERCULOUS ADENITIS 

Tuberculous adenitis is a term applied by common consent to 
tuberculosis of the cervical lymph-nodes. In cases of early and local- 
ized tuberculous involvement, these glands, more often than any other 
structures, harbor the bacilli. Furthermore, because of the possibility 
of ready access to the source of the disease, these cases present a 
better prognosis as regards its eradication than do cases of tuberculosis 
in any other part of the body. 

Age. — The age incidence is interesting. Cases are rarely seen before 
the third year and do not often develop after the eighth year. I have 
known cases, however, to develop much later. My oldest patient was 
a girl sixteen years of age who was otherwise healthy. 

Conditions Favoring the Development of Lymph-node Tuberculosis. 
— Diseased tonsils and adenoids are the most fruitful cause of tubercu- 
lous cervical lymph-glands. 

Whether previous inflammatory condition of the glands makes 
them a more favorable host is not known ; neither do we know when the 
glands become tuberculous. Is the tubercle bacillus the first offender? 
Holt believes that in most cases tuberculosis is the primary infec- 
tion. Heredity probably plays no part in causation. That lympha- 
tism may predispose an individual to the infection is extremely doubt- 
ful. It has not been my observation that children predisposed to 
glandular enlargement from some systemic cause are especially sus- 
ceptible to bacterial infection. It is my belief that tuberculous glands 
are dependent for the infection upon the presence of tubercle bacilli in 
the food and air, and upon a means of communication to the gland 
which is perfectly supplied by those lymphatics whose function it is 
to drain bacteria-laden tonsils and adenoids. 

Contributory to this belief is the fact that the age from the third 
to the eighth year is the period during which diseased tonsils and 
adenoids are of the most frequent occurrence. 

Types of Infection. — In the majority of cases of primary cervical 
adenitis in children the tubercle bacilli, which have been isolated by 
observers in this country, England, and Germany, have conformed to the 
human type. From bronchial and mesenteric lymph-nodes affected 
with tuberculosis in young children Gofflsey isolated the human 
type in 55 out of 57 cases. In two the bovine strains were present in 
the bronchial nodes. Tuberculous glands which have undergone 
suppuration are usually the seat of a secondary infection with the 
streptococcus. 

Symptoms. — A symptomatology of value in tuberculous adenitis is 
most difficult, as we do not know positively when a gland becomes in- 



TUBERCULOUS ADENITIS 



421 



fected. Knowledge of very early symptoms is therefore out of the 
question. Cervical glands are prone to enlargement. One or more 
may enlarge and disappear or diminish in size, and enlarge again and 
disappear and never trouble the child thereafter. In another case per- 
haps the same phenomenon occurs, but the glands do not diminish in 
size or disappear as formerly, but, on the contrary, remain enlarged. 
In well-developed adenitis the glands cease to be movable. A peri- 
adenitis binds them to the skin and the adjacent tissue and probably 
to the adjacent glands. 
The involved glands may 
be small or large. I have 
repeatedly seen tuber- 
culous glands as small 
as a pea undergoing 
typical cheesy degenera- 
tion. Usually one side 
of the neck is involved. 
Secondary infection is 
productive of abscess; 
the skin over the super- 
ficially seated gland be- 
comes acutely reddened 
and breaks down if not 
opened, discharging thin, 
light-yellow pus. Other 
glands undergo the same 
process of infection, fol- 
lowed by cheesy degen- 
eration and suppuration, 
with the formation of a 
sinus and destruction of 
skin. Attempts at reso- 
lution produce cicatricial 
changes which add to 
the unsightliness of the 

wound. The entire process is a chronic one, and requires years to 
produce the clinical picture represented in Fig. 51. 

Prognosis. — The prognosis is the same as in so many diseases in 
which the treatment is surgical. The outlook is most satisfactory if 
the surgeon is given an opportunity to operate early. The girl of 
sixteen years previously referred to was undergoing treatment for 
tuberculous nodes by means other than operation. After three months 
of treatment she developed tuberculous meningitis. This incident 
occurred very early in my medical career. 

Treatment. — My present position is as follows : If the gland may be 
diagnosed as tuberculous, surgical procedures should be brought into 
the case. If the diagnosis is not positive, but the gland or glands 
remain persistently enlarged to a degree sufficient to produce a de- 




Fig. 51. — Cicatrices following a neglected case 
of tuberculous adenitis in a girl seven years old. 
There is also a tuberculous patch upon the skin of 
the cheek in a very frequent location (Holt). 



422 THE PRACTICE OF PEDIATRICS 

formity, the case should be placed in the suspected class and opera- 
tion should be performed. 

The operation is usually attended with most satisfactory results, 
but should be attempted only by a competent surgeon. I have known 
results that were not satisfactory. The possibilities of an unsightly 
scar deter many parents from assenting to an operation. If the opera- 
tion is performed by the Dowd method* before ulceration of the skin 
develops, the scar is neghgible. Long before adult life is reached it 
will not be visible. 

After the operation the child should, if possible, be given the ad- 
vantage of an outdoor life in the country, inland. These cases appear 
to improve most rapidly at an elevation of 800 feet or more. The diet 
should consist of meat, eggs, milk, and of high-proteid cereals, such as 
oatmeal and the dried legumes, given in the form of purees. It is my 
custom to order cod-liver oil and malt to be given in doses of from 
one teaspoonful to one tablespoonful after meals for one week, 
followed for one week by the syrup of the hypophosphites. The oil 
and malt may then be resumed for the same time, thus alternating in- 
definitely with the hypophosphites. If an examination of the blood 
shows that the patient is anemic, iron may be used in connection with 
the other remedies. The citrate of iron and extractum ferri pomatum 
are well borne by the stomach, and have appeared to be of considerable 
service in some of my cases. To children from five to ten years of 
age one grain of the citrate of iron and quinin in sherry wine, or one 
grain of citrate of iron and ammonia in water, may be given after 
meals. The dose of extractum ferri pomatum at this age is one-half 
grain after each meal. 

MASTITIS IN YOUNG GIRLS 

Inflammation of the mammary gland in young girls is a compara- 
tively rare condition, but one of sufliciently frequent occurrence to re- 
quire mention. Swelling and tenderness of the breasts, although often 
complained of by young girls about the time of puberty, subside 
without treatment if let alone. My cases of true mastitis have varied 
in age from seven to twelve years. The condition is usually due to the 
entrance of bacteria through the nipple, and in its clinical manifesta- 
tions it resembles mastitis in the adult, except that the entire gland 
is usually involved, becoming swollen, tender, and excruciatingly pain- 
ful. There is slight fever, — not above 101°F., — headache, and 
lassitude. 

Treatment. — Satisfactory treatment during the acute stage has 
consisted in the use of an ice-bag, which is kept constantly applied 
during the waking hours. At night a wet dressing of bichlorid of 
mercury, 1 : 5000, should be kept on the infected glands. A saline laxa- 
tive in the form of citrate of magnesia should be given at the onset, 

* Surgery, Gyn. & Obs., vol. viii,pp. 232-237, Mar., 1909, and Journ. A. M. A., 
vol. Ixvii, pp. 499-503, Aug., 1916. 



THE THYMUS GLAND 423 

and a diet of broth, gruel, toast, and stewed fruit is to be continued 
during the period of fever. Recovery is usual under two weeks. The 
ice-bag has not been required for more than three or four days. After 
this period the wet dressing answers the same purpose. 

THE THYMUS GLAND 

The thymus consists of two lobes, faintly red in color. They are 
more or less pointed toward the upper part, rounded off toward the 
lower, and bound together with loose connective tissue. The organ is 
situated in the anterior mediastinum, and the greater portion of the 
gland lies behind the manubrium and body of the sternum. Sappey 
has demonstrated that the thymus in the new-born infant reaches from 
the upper edge of the manubrium 5 cm. downward, while the upper 
border at times may reach the isthmus of the thyroid, or be 2 to 3 cm. 
below it. The sides and lower portion are covered by the folds of the 
mediastinum, while the anterior borders of the lungs and loose connec- 
tive tissue separate the gland from the chest- wall. Posteriorly, the 
gland covers the pericardium in its upper two-thirds, and the beginning 
of the great vessels. Its elongated upper edges cover the trachea. The 
vagi and phrenic nerves and common carotid arteries bound it on 
either side, while posteriorly, again in close relation, are the phrenic 
nerves. The average width is 2 to 3 cm., and at times the longitudinal 
diameter may reach 113-^ cm. 

Weight and Size. — As found postmortem, the size and weight of 
this gland-like organ vary considerably, and, at the present time, there 
is a wide variation of opinion respecting the normal. Probably the 
most exhaustive work on this point was done by Bovaird and Nicoll, 
who weighed the thymus in 495 consecutive autopsies, the results of 
which were published in 1906. They found the greatest weight at 
birth, the average being 7.7 gm. Following this there was little change 
until the period of five years was reached, from which time a gradual 
reduction took place. Judging from these observations, one may con- 
clude that the average weight at birth is 6 to 7 gm. ; from birth to five 
years, 3 to 4 gm.; and that any weight over 10 gm. may be considered 
abnormal. 

Olivier, in his extensive monograph, gives the following figures: 

Birth 4 gm . 

1 year 6 " 

2 years 8 " 

3 "^^ 10 " 

He considers all thymi over 15 gm. to be hypertrophied. Sappey, 
Murkel, and Testut all quote figures higher than Olivier. Friedleben 
and other observers pointed out, some time ago, that these variations 
in the weight and size of the thymus may be accounted for by the body 
nutrition. It appears that the thymus shows the results of excessive 
loss much more than the body as a whole, for in exhausting diseases 
the weight of the thymus sinks much more rapidly than that of the 



424 THE PRACTICE OF PEDIATRICS 

body. In exceptional cases the reverse is true. Formerly the thymus 
was supposed to reach its maximum at birth, and subsequently to 
atrophy, but more recent observations have shown that remnants per- 
sist until puberty, and that true thymus tissue may persist throughout 
life. 

In status lymphaticus the thymus often weighs 5 to 10 times more 
than normal. In well-marked cases its weight may be as high as 55 gm. , 
and in less pronounced cases range between 10 and 20 gm. As a whole, 
the hypertrophied thymus is a little more vascular than normal, but 
aside from hyperplasia, shows no other consistent changes macroscop- 
ically or microscopically. 

Palpation. — Palpation of the thymus does not give any points by 
which to estimate its size. The deformity commonly known as 
'' pigeon-breast '' is not even remotely associated with an enlarged 
thymus. 

Functions. — Physiology. — The physiology of the thymus is indeed 
very obscure, little being known about its functions. Its closeness to 
the thyroid and parathyroid glands and its similarity of origin would 
almost suggest that it played some specific part in metabolism, but 
physiologic experiments of late have failed to discover exactly what this 
influence is. 

During the past few years there has been considerable experimenta- 
tion relative to the thymus, which, so far, has apparently cleared up the 
matter in two directions, namely: the relation of the organ to bone 
growth and to the condition of the bones, on one hand, and to the 
electric excitability of the nerves on the other. Basch has shown that 
following complete extirpation of the thymus in a young dog there 
occurs a softening of the bones and a check to their growth ; in fact, a 
condition very much resembling rickets and chondrodystrophy. At 
the same time the peripheral nervous system shows an increased electric 
excitability. Numerous other observers have confirmed these observa- 
tions, and, in addition, have noted that in thymectomized animals 
there exists a stage of increased fat absorption and later malnutrition 
and cachexia. 

STATUS LYMPHATICUS 

It is well proved by a long series of cases, carefully studied by com- 
petent observers, that the condition known as status lymphaticus is an 
entity and is characterized clinically by a lowered vitality or an un- 
stable equilibrium of the vital forces, so that accidents or disturbances, 
otherwise unimportant, such as some slight injury or anesthesia, may 
precipate failure of the heart and respiration. 

In status lymphaticus there is hyperplasia of the thymus and some- 
times general lymphatic gland involvement. 

Pathology. — The thymus often weights 5 to 10 times more than 
normal. In well-marked cases its weight may be as high as 55 gm., 
and in less pronounced cases range between 10 and 20 gm. As a whole 
the hypertrophied thymus is a little more vascular than normal, but 



STATUS LYMPHATICUS 



425 



aside from hyperplasia, shows no other consistent changes macroscop- 
ically or microscopically. 

Autopsy findings in these subjects usually show a general lymphatic 
enlargement of tonsils and follicles at the base of the tongue and intes- 
tine and swelling and enlargement of the thymus, especially at an age 
when it has generally disappeared. 




Fig. 52. — Enlarged Thymus. The lungs, heart, and thymus are shown in the 
picture. The lungs have been turned back, showing the two lateral lobes of the 
thymus overlapping the heart; the central lobe, above, covers the trachea. 
History. — Breast fed, male child, nine months old, well developed; ill less than 
twenty-four hours; d^^spnea, slight cyanosis, with death from asphyxia. T. 103°F. 
Autopsy. — Besides the large thymus there were present the general lesions of the 
status lymphaticus to a marked degree; lungs deeply congested (from Holt's 
"Diseases of Children," D. Appleton and Company, Publishers). 

Etiology. — An explanation of the disease worth recording has 
never been offered. The symptoms may be almost identical with 
laryngismus stridulus. There are sudden repeated at-tacks of croupy 
voice, inspiratory obstruction, cyanosis, apnea, and loss of conscious- 
ness which may last from a few seconds to minute or two. In not every 
instance is the above sequence of events carried out. The attacks may 
cease at any stage, or the child may never recover consciousness. 

The above clinical picture, with later proved thymic death, has 
occurred under my own observation several times. On the other hand 



426 THE PRACTICE OF PEDIATRICS 

the first sign of trouble in two perfectly well-nourished infants was a 
convulsion and both children died in the seizure. There had never been 
a previous convulsion or laryngeal stridor. Autopsy in both showed an 
enlarged thymus. 

Cause of the Sudden Death. — The explanation of the deaths occur- 
ring in these infants — most frequently during the first eighteen months 
— is very difficult, and in many cases a careful autopsy does not clear up 
the situation. Many extraordinary hypotheses have been advanced. 
Some believe that pressure exerted by the hyperplastic thymus on the 
vital organs in this region is sufficient to account for the deaths. 
Others are convinced that the pressure exerted by this gland is suffi- 




; 




Normal medias- 
tinum 



Heart 




Fig. 53. — Normal thymus. 

cient to produce tracheal stenosis, although such a belief seems far 
fetched when one considers the weight of the thymus and contrasts it 
with the fibrous tracheal rings. 

The occurrence of a sudden swelling has not yet been proved, 
neither has the theory of a narrowed thoracic outlet, which might be 
still more narrowed by a forceful extension of the head, received much 
support. It does not seem possible that such a powerful vessel as the 
aorta, which is capable of eroding bones, could be pressed upon, with 
fatal results, as is suggested by some authors. 

Many of the sudden deaths occurring during chloroform and ether 
anesthesia have proved to be due to status lymphaticus. 

According to Paltauf's many extensive observations, the cause, 
apparently impossible to explain, lies in a peculiar constitutional 



STATUS LYMPHATICUS 



427 



anomaly, which makes its possessor weak, and less able to stand attacks 
of illness, death being easily produced from trifling causes. 

Diagnosis. — Other than the clinical signs we have the Roentgen 
ray and percussion to aid us in diagnosis. 

Percussion. — Percussion of the thymus has been carefully studied 
by Blumenreich, and is of much greater value than palpation, although 
neither of these methods have received much support in this country. 
Many instruments have been devised for percussion, but no two men 
agree on the results obtained. 

Blumenrich found the dulness of the thymus to cover a space some- 
what triangular in outline, the base being represented by a line drawn 
across the top of the manubrium between the sternoclavicular joints, 



Enlarged 
thymus 



Heart 




Fig. 54. — Enlarged thymus. 



while the rounded-off point or apex was found to lie about on a line 
with the second rib. Between this thymus dulness and the normal 
cardiac dulness on the left side is a zone normally filled in by lung tis- 
sue; if this area be dulled and if all other causes of impairment can be 
excluded, then a diagnosis of enlarged thymus is justifiable. Among 
other workers the names of Basch and Rohn may be mentioned. In 
their outUning of the thymus they found it to be more rhomboid 
in contour, but, on the whole, tended to confirm the older work of 
Blumenreich. 

Roentgen Ray. — Roentgen ray examinations have been as a rule 
unsatisfactory in my cases. Figs. 53 and 54 represent a radiograph by 
Cole of New York in which a normal and an enlarged thymus are shown. 
The radiograph showing the enlarged thymus was made from a patient, 



428 THE PRACTICE OF PEDIATRICS 

five months of age. The child was premature and had shown since 
birth a tendency to attacks of mild cyanosis. The child was nursed by 
the mother and made satisfactory progress along nutritional lines. 
Without any illness or the occurrence of anything of a nature to explain 
the seizure, the child became markedly cyanosed, respirations ceased and 
the child's life was despaired of. Under active stimulation and arti- 
ficial respiration by the trained nurse in charge, respiration was with 
much difficulty re-established. During the next few weeks there were 
attacks of cyanosis of a less serious nature. Roentgen ray treatment 
was carried out by Cole. There has been no attacks of cyanosis for 
several months. The child apparently has completely recovered. 

Treatment. — Removal of the thymus has been practised on a 
limited scale with unsatisfactory results. The mortality is high and 
with the thymus removed there is the probability of defective growth 
and development as has been observed in thymectomized animals. 

The Roentgen Ray. — Treatment by means of the oj-ray has been 
successfully carried on by Friedlander.* In my own patients five have 
been given the a;-ray treatment. I am not prepared to pass upon its 
value. 

DYSPITUITARISM. DYSTROPHY ADIPOSOGENITALIS (FROHLICH) 

This disease represents the manifestation in the organism of di- 
minished function of the anterior lobe of the pituitary gland. The 
loss of function, according to Gushing f may be due to tumor pressure or 
disease. This portion of the gland is associated, according to this 
author, with the metabolism of fat, with sexual activities, and is closely 
related in an obscure way with the functions of all the other ductless 
glands in the body. Gushing believes that sexual infantilism is due 
to diminished secretions of the pituitary body, there not being sufficient 
to activate testicular and ovarian functions. 

Symptoms. — In this disease the patient is short in stature, very fat 
and with a marked lack of sexual development, the penis and 
testicles in boys remaining almost infantile in size. There is an 
absence of pubic hair in both sexes. Boys show decidedly feminine 
characteristics. 

Six cases of dyspituitarism have come under my observation. 
5 were boys, ranging from eight to sixteen years. I have seen but one 
case in a girl, ten years old. 

Treatment. — The administration of the anterior lobe extract is 
advised by Gushing in hypo-pituitarism. He states that many of 
these cases have been benefited in the past by thyroid administration, 
due to an indirect reawakening of the activities of the hypophysis and 
possible secondary activities in the semative organs. 

The administration of thyroid in small doses, one-fifth of a grain 
three times daily with three grains of anterior lobe extract, have shown 
no appreciable results in my own cases. 

* American Journal Diseases of Children, vol. vi, p. 38-56. 
t Journal A. M. A., July 24, 1909, p. 249. 



Xn, THE UROGENITAL SYSTEM 
The Urine 

Tables dealing with the frequency of urination and the specific 
gravity of the urine for the different ages of childhood are necessarily 
inaccurate, particularly when they refer to children under one year of 
age. 

Urinary Observations. — At the New York Infant Asylum several 
years ago Dr. George T. Myers, at that time resident physician, made 
a series of investigations under my direction relating to the various 
phases and functions of the newly born infant, which differed from some 
of the observations previously recorded. The series comprised 45 cases. 
Among other observations was one as to the time of the first micturi- 
tion after birth. It was found that the time varied greatly. In fifteen 
micturition occurred simultaneously with birth ; in ten, in less than four 
hours; in eight, in from four to eight hours; and in the remainder, 
ranged between eight and eighteen hours after birth. In but two cases 
was the interval longer than fourteen hours. It was also found that the 
specific gravity, the frequency of urination, and the amount of urine 
passed were subject to wide variations within normal Hmits. These 
various features depended upon whether the infant was breast-fed or 
bottle-fed, whether a girl or a boy, and whether, if the baby was breast- 
fed, the mother had a scanty or a free flow of milk. The bottle-fed 
always passed more urine than the breast-fed. The quantity of urine 
is also influenced by the clothing worn and by the season of the year. 

Normal Variations. — Normal variations occur, therefore, within very 
wide limits. One child will pass urine every thirty minutes when 
awake; others, of equal health and age, will retain it for three hours. 
Before the child takes much fluid, particularly in the first days of life, 
from two to five ounces is probably passed in twenty-four hours, with 
a specific gravity of 1.005 to 1.010. Infants urinating very frequently 
are apt to develop into bed-wetters in later life, probably owing to the 
undeveloped condition of the bladder, the size of that viscus remaining 
small. In other respects, very frequent urination, in the absence of 
signs of illness, is of no significance in the young. After the feeding is 
established, the specific gravity wiU range from 1.003 to 1.012 from 
the second week to the second year. A baby nine months old will pass 
an average of about twelve ounces of urine in twenty-four hours. At 
the sixth year, from sixteen to twenty-five ounces with a specific gravity 
under 1.015 will be passed. From this age until puberty both the 
quantity and specific gravity gradually increase, the usual range in 
specific gravity being from 1.010 to 1.020. 

429 



430 THE PRACTICE OF PEDIATRICS 

Method of Collecting Urine. — The collection of the amount voided 
in twenty-four hours by children of the ''runabout" age is difficult, 
and in young infants well-nigh impossible, except in a metabolism bed. 
For accurate work the specimen should be obtained by the catheter. 
When for any reason this is not possible, there are various devices for 
collecting the urine, any one of which may be tried. The tying on of 
a wide-mouthed bottle or a condom in boys, fastening it with adhesive 
strips to the body, is often successful. Absorbent cotton into which 
the child urinates, the urine being expressed from this into a bottle, may 
be used for either boys or girls, as may also the Chapin collector. The 
chief disadvantage of any of these measures is the certainty of con- 
tamination. The urine so collected may answer for an examination for 
albumin, sugar, or the renal elements, but is useless for a bacteriologic 
study. 

Continence Established. — From the second to the third year conti- 
nence at night is usually established. If incontinence continues after 
the third year, the case should be looked upon as abnormal and receive 
treatment accordingly. (See Incontinence of Urine, p. 432.) 

DIFFICULT AND PAINFUL URINATION 

Painful urination is of frequent occurrence in infants and ''run- 
about" children. It may be due to irritation at the urethral outlet 
following injury, or to scalding from acid urine. Not infrequently the 
irritation is due to lack of cleanliness of the parts. In boys with long 
foreskins which remain moistened the urine undergoes decomposition, 
and inflammation about the orifice of the urethra is the result. In girls 
dysuria is often due to a hardly discernible inflammation about the 
orifice of the urethra, occurring in association with vulvitis or vulvo- 
vaginitis. 

In two cases I have found calculi in the urethra. Both patients 
were boys about five years of age. By far the greater number of pa- 
tients who suffer from difficult micturition are boys who have phimosis 
with adhesions and retained smegma. Attention to the external geni- 
tals in the matter of cleanliness, the operation of circumcision, or the 
rehef of adhesions by slitting the foreskin and freeing the glans promptly 
reheves the condition. Among the operative procedures, only cir- 
cumcision should be employed. As a temporary measure the dorsal 
slit may suffice. 

RETENTION AND SUPPRESSION OF URINE 

In using the above terms with reference to diseases of the urinary 
organs it is well to appreciate their significance. By suppression is 
meant a condition of anuria in which no urine is passed into the bladder, 
that viscus being found empty on catheterization. In retention the 
urine is secreted by the kidneys and passed into the bladder, but is not 
voided. When the urine is not voided, we must always ascertain 



RETENTION AND SUPPRESSION OF URINE 431 

whether there is suppression or retention. If there is retention, this 
fact may usually be discovered by palpation and percussion. In fat 
children a positive diagnosis may be impossible by this means. In the 
event of doubt, a catheter should be employed. For infants under one 
year of age a soft-rubber catheter, No. 4 or 5 American, should be used. 
The bladder of the infant and young child is very readily infected and 
care should be exercised to have the catheter sterile. If suppression is 
diagnosed and treatment by diuretics is instituted, when actually there 
is simple retention, no Httle trouble will result, as I have occasionally 
seen. 

Suppression of the urine may persist for hours without any grave 
pathologic condition of the kidneys. Chilling of the skin surface may 
be a cause. In acute gastro-intestinal disorders with frequent vomiting 
and watery stools suppression may exist for twenty-four hours. The 
secretion is reestablished when there is again an available fluid to be 
added to the circulation from the digestive tract. If the suppression 
is due to causes of a grave nature, such as acute nephritis, there 
will usually be signs of other trouble, such as vomiting, fever, and 
edema. 

Retention may result from an injury to the urethra, or from vagi- 
nitis, or from phimosis. Impacted stone in the urethra was a cause in 
two boys seen by me. Fortunately in each case the stone was located 
near the meatus and readily removed. 

Treatment. — Retention. — The immediate relief of retention is by 
catheterization. Further treatment consists in the correction of the 
exciting cause. If a catheter is not at hand, the application of a hot 
stupe over the lower portion of the abdomen and the genitals may be 
sufl&cient to stimulate urination. 

Suppression. — Colon flushing is one of the most effective measures 
of relieving suppression of the urine. The apparatus required and the 
methods employed will be found on page 795. If the temperature of 
the patient is not above 102°F., normal salt solution, at a temperature 
of 110°F., is advised. I have always found flushing more effective 
when this degree of heat was used. One pint is introduced for a child 
three years of age. In children of one year or under, from 4 to 8 ounces 
is all that will be retained. The enema must not be repeated, however, 
oftener than once in six or eight hours, as the colon of a child soon be- 
comes intolerant of the injections and but little will be retained. Re- 
peatedly, after the first injection, the kidneys have resumed activity 
when all other means had failed. This method has been particularly 
useful in cases following or accompanying the exanthemata, when 
there was an acute nephritis with greatly diminished secretion of urine. 
A large hot poultice of flax-seed meal about 2 inches thick and 
sufl&ciently large to cover the lumbar and lower dorsal regions will 
often act surprisingly well in establishing the kidney function. The 
treatment should be continued for at least one hour, using three 
poultices during this time. 



432 THE PRACTICE OP PEDIATRICS 

INCONTINENCE OF URINE (ENURESIS) 

In enuresis there is an involuntary emptying of the bladder. 

Enuresis diurna is the involuntary emptying of the bladder during 
the waking hours. 

Enuresis nocturna is the involuntary emptying of the bladder during 
sleep. 

Involuntary discharge of the urine is normal in the young infant. 
Urination becomes a voluntary function at an age depending largely 
upon the child's training. In most children, with the right kind of 
management, the function may be controlled during waking hours by 
the tenth month. 

During sleep, involuntary urination continues to a later period, and, 
while in many perfect control may be established at the completion of 
the second year, I do not regard the lack of control as abnormal until 
the third year is completed. If, during the second year, the child 
shows a tendency to frequent urination and involuntary passage of 
urine during the waking hours, with habitual incontinence at night, it 
is my custom to advise preventive measures. 

When the incontinence persists during the waking hours at the 
completion of the second year, or during sleep at the completion of the 
third year, the condition is regarded as abnormal and the child is placed 
under treatment. . 

Etiology. — Deformities and Abnormalities. — The condition may be 
due to a congenitally small bladder, with very little holding capacity. 
A girl who came under my care for treatment for incontinence by day 
and night had a bladder the holding capacity of which was but one 
ounce. With such lack of development of the bladder, obviously there 
must be incontinence. In spina bifida it may occur as a result of 
paralysis of the pudic nerve supply to the neck of the bladder; a con- 
genitally large urethra may also be a cause. 

Peripheral causes acting through reflex irritation are not infre- 
quently encountered. 

Thus, incontinence may be due to a vaginitis, to an adherent 
clitoris, or to phimosis. It may be due to thread-worms in the rectum, 
to constipation, to stone in the bladder, to cystitis, or to hyperacidity of 
the urine. 

The diet may also play a part. The use of highly nitrogenous food 
in large amounts or a diet rich in sugar may lead to changes in the urine 
sufficient to cause the trouble. 

Excessive bed-clothing and the habit of sleeping on the back have a 
bearing in the causation. 

Adenoid vegetations in considerable amount in the. nasopharyngeal 
vault are looked upon by some authors as an etiologic factor. Those 
afflicted with diabetes insipidus (polyuria) or diabetes mellitus, because 
of the large amount of urine passed, are very apt to suffer from 
incontinence. 

Weakness of the sphincter is supposed to play a part in causing in- 
continence, particularly loss of control when awake. 



INCONTINENCE OF URINE (ENURESIS) 433 

Cases of Nervous Origin, — The nervous control of the bladder is 
dependent upon a cerebral center and a sacral center, each receiving 
and sending out impulses. 

It is not difficult to understand how a lack of coordination from 
faulty development of the sympathetic mechanism might occasion in- 
continence. After all possible dietetic errors and irritations acting re- 
flexly through the above nerve mechanism are excluded, about 90 per 
cent, of our cases remain unexplained. This group represents the cases 
usually chronicled as due to a neurosis, absence of coordination due to 
failure of sufficient development of the nerve-centers. 

Diagnosis. — The patient always has a ready-made diagnosis. 

Prognosis. — The prognosis depends largely upon the physician and 
the child's parents or attendant. Great patience and persistence are 
necessary. All cases are curable except when an anatomic abnormality 
exists. In many instances the response to treatment is very prompt. 
In others it is tedious, several months being required before we are 
sure that the cure is complete. 

A fact to be taken into consideration in making a prognosis as to 
the probable duration of the treatment in a given case is the size of the 
bladder, since a child who has suffered from incontinence both by day 
and night may have a small and contracted bladder, because of lack of 
development from disuse. The most reliable means of determining the 
size of a bladder is by measuring the amount of sterile water which can 
be introduced through a catheter. 

Treatment. — In assuming the care of a child with enuresis, obviously 
it is most necessary to learn the cause of the trouble. Two or three 
examinations of the urine should be made, and if this is found persist- 
ently acid and of a specific gravity over 1020, a reduction in the ni- 
trogenous food-stuffs is necessary before beginning medication. If the 
enuresis is due to peripheral causes, they must be corrected and the 
general physical condition of the child improved, although in my ex- 
perience the delicate and chronically ailing are not the children who 
are the greatest sufferers, by far the larger number of my patients hav- 
ing been well-nourished children who were otherwise normal. Long- 
continued incontinence does not appear to affect the general health. 
When well established, the condition, untreated, usually continues 
until the child is eight or ten years of age. I have known of a few cases 
which persisted until puberty, or later. 

If no improvement follows the removal of aU possible dietetic and 
peripheral causes, — acidity, phimosis, worms, constipation, etc., — 
we must assume that we have an idiopathic incontinence to deal with. 
If the case is one of nightly incontinence of several months' or years' 
standing, we must positively acquaint the mother with the fact that 
prolonged treatment will in all probability be required, and that unless 
her active and continued cooperation is assured the treatment of the 
case will not be undertaken. 

With the very definite understanding that no brilliant results are 
immediately expected, the following scheme of management is inaugu- 
28 



434 THE PRACTICE OF PEDIATRICS 

rated : The child receives three meals daily. The breakfast and dinner 
correspond to the age of the child, but with the important exception 
that red meat is to be given but once during the twenty-four hours, 
and only at midday. The supper, which should not be later than 6 
o'clock, I designate as a "dry supper/' It may consist of any cereal, 
such as rice, hominy, farina, or wheatena, served with butter and sugar. 
If this is not well taken, a small quantity of both sugar and milk may 
be added. Permissible articles for the evening meal in addition to the 
above are: ice-cream, milk toast, blanc-mange, jelly, stewed fruit, 
bread and butter, junket, and corn-starch. Meat, eggs, or heavy 
foods of any kind should not be given at night. 

Abstinence from Fluids. — One pint of water and one pint of milk 
only are allowed in 24 hours in persistent cases. At 4 o'clock in the 
afternoon the child may be given a half -glass of water or milk, but after 
this time no fluids are to be allowed other than a scant ounce of milk 
on the cereal. The withdrawal of all fluids after 4 p. m. will at first 
be a hardship for some children, and they may be allowed three or 
four ounces of milk or water with the evening meal; but this quantity 
should gradually be diminished until at the end of a week it will not 
be missed. 

Night Management. — The patient should be as lightly covered at 
night as comfort will permit. There is less tendency to incontinence 
if the child rests on the side or stomach, and sleep in this position should 
be encouraged. In dealing with inveterates, for whom every possible 
aid is brought into use, I have used the knotted towel as a means of 
keeping the child off his back. The towel, knotted in the middle, is 
passed around the child so that the knot will rest on the back. The 
ends of the towel should then be pinned together over the abdomen like 
those of an abdominal binder. When the patient attempts to rest on 
the back the knot causes discomfort and the position is changed. At 
10 or 11 o'clock, when the person in charge retires, the child should be 
taken up to urinate. 

Drugs. — Without a strict observation of the above measures, par- 
ticularly those referring to diet and abstinence from water after 4 p. m., 
drugs are of no value, whatever their method of administration. With 
the above suggestions carried out, we have one remedy which is of great 
value, and that is belladonna. For convenience of administration I 
prefer the alkaloid, atropin. To insure full benefit in severe cases the 
drug must be pushed until we obtain the physiologic effect, as shown 
by slight dilatation of the pupils. Before beginning the treatment it is 
well to advise mothers that redness of the skin need cause no alarm, 
but calls for the discontinuance of the drug until further instructions 
are given. The atropin is administered in a solution of one grain to an 
ounce of water; one ounce of water contains approximately 500 drops, 
so that one drop of the atropin solution will contain approximately 
3-^00 grain of the drug. The mother is given a chart containing the 
directions for administration, which for a child five years of age are as 
follows : 



INCONTINENCE OF URINE (ENURESIS) 435 



1st day 

2d " 


4 p.m. drop 


7 p. M. 

it 

(I 

u 

Si 

ii 
(( 


1 drop 
1 


3d " 


" 1 '' 


2 drons 


4th " 


" 2 drops 


2 
3 
o 

4 
4 
5 
5 


! 


5th *' 


" 2 " 




6th '' 


" 3 




7th '' 


" 3 " 




8th " 


" 4 




9th " 


'' 4 " 




10th " 


" 5 " 





The maximum dose given is one drop daily at 4 and 7 p. m. for 
every year of age. Thus, for a child three years old the dosage should 
not be greater than three drops, twice daily; for a child six years old 
not over six drops, twice daily. It may be well, if the case is not 
under close observation, to make a more gradual increase in the 
dosage than the above, so as to avoid the possibility of unpleasant 
physiologic effects. 

It is never necessary to exceed these doses even with older children, 
for the reason that the amounts given are sufficient to control the 
enuresis; and the dilated pupils and bellg-donna blush which follow an 
increased dosage show that such increases are imprudent. 

The tolerance of atropin varies considerably, although children 
usually bear it very well. Now and then a child is treated who cannot 
take more than two drops (M50 grain) daily. To one boy eight years 
of age but Hoo grain could be given twice daily. 

Pronounced benefit, ordinarily, will not be observed during the first 
week or two of treatment. If the child suffers from incontinence while 
awake, this will first be cured. The improvement in nocturnal incon- 
tinence is more gradual and may be considerably delayed. Thus, no 
improvement whatever may be seen for two or three weeks. In the 
average case the improvement is gradual. At first there wiU be nights 
at short intervals when there will be very slight incontinence, or none 
at all. Usually, after a few weeks' treatment the incontinence entirely 
ceases. 

The mistake frequently made is to stop the atropin at this point. 
When this is done, there is usually an immediate return of the trouble. 
The full treatment should be continued until the child has not wet the 
bed for at least two weeks. The daily amount of atropin should then 
be reduced one-half and kept at this point for six weeks. If at the end 
of two months from beginning treatment there is no incontinence, the 
drug may be discontinued, but the dietetic restrictions, particularly the 
"dry supper," should be maintained three months longer. It must be 
remembered that the habit which has become estabhshed is hard to 
overcome, even after the neurosis and the weakness of the sphincter 
have been corrected. 

Strychnin and tincture of cantharides have been advocated by 
pediatric writers. For weak, poorly nourished children strychnin 
added to the iron or oil may be of service in improving the general con- 
dition of the patient, and indirectly aid in the treatment of the enuresis. 

When incontinence occurs only during the day, the dietetic regula- 



436 THE PRACTICE OF PEDIATRICS 

tions are the same, with the exception that the fluids allowed need not 
be curtailed unless the quantity is excessive. The dosage of atropin is 
the same, but the time of administration should be changed to after 
breakfast and after luncheon, instead of at 4 and 7 p. m. In addition 
to the atropin, strychnin should always be given in cases of inconti- 
nence by day, for in such cases a lack of development or a relaxation of 
the s hincter is more of a factor than is failure of nerve coordination. 

HEMATURIA (BLOOD IN THE URINE) 

The presence of blood in the urine may be due to readily discernible 
causes; or when small (microscopic) amounts are present, the cause 
may be most difficult to determine. 

Highly concentrated urine may be sufficiently irritating to produce 
the passage of microscopic amounts of blood. Blood and albumin are 
not of infrequent occurrence in the urine of the newly born and during 
the first weeks of life, because of the presence of uric acid in large 
amounts peculiar to this period of life. 

Among the possible causes of blood in the urine are : 

Acute nephritis. 

Scarlatina. 

Hemophilia. 

Purpura hsemorrhagica. 

Scurvy. 

Trauma. 

Calculi. 

Malignant growth of the kidney. 

Tuberculosis of the kidney or bladder. . 

Certain drugs taken into the stomach. 

HEMOGLOBINURIA 

In this condition the urine contains the coloring-matter of the blood, 
with few, if any, corpuscles. There may be a small amount of albumin. 
The urine may be light red, brown, or even black. In a child one year 
old who died from creasote poisoning the urine was almost black. This 
case was seen in consultation. In another case of a child three years 
of age with malaria the urine was of a deep brown color. 

Paroxysmal hemoglobinuria is of very rare occurrence in this 
country. In tropical countries, where severe forms of malaria are 
common, the condition is not unusual. It is due to some atoxic agent 
or ferment which dissolves the coloring-matter out of the blood. 

PYURIA 

Pus in the urine in the young is usually the result of a cystitis, 
cystopyelitis, or pyonephrosis. 

Illustrative Case. — A hospital patient, about eighteen months of age, showed 
periodically large amounts of pus in the urine. Pus would be present in the urine 
for a few hours, and then, for two, three, or more days, the urine would be perfectly 
clear and free from pus. 



GLYCOSURIA 437 

Autopsy showed that although one kidney was normal, the other had undergone 
cystic degeneration, the pelvis being greatly dilated and filled with pus. The ureter 
was thickened and partially occluded. When the sac had become filled with pus, 
and the child was in a favorable position, the pus probably discharged into the 
bladder. 

Pyelonephritis may be the result of a pyelocystitis. 

Illustrative Case. — A child eleven months of age had pyelitis, evidently pri- 
marily, which had not been recognized. The temperature ranged very high, — 
105° to 107''F., — and the child died from exhaustion and anemia. Autopsy 
revealed an extensive pyelitis with multiple abscesses scattered throughoiit the 
kidney structure, varying in size from a pin-point to a pea. 

Such cases as the foregoing, it is understood, are of very unusual 
occurrence. In still rarer instances the pus may be due to an abscess, 
phrenic or of other type which may open into the urinary tract. 
When pus is present in the urine, the source is usually the bladder 
(cystitis) or the pelvis of the kidney (pyelitis). 

Specific urethritis (gonorrhea) will give rise to pus in the urine. 
Gonorrhea, however, is of very unusual occurrence in boys, and when 
present, it is suflficiently active to leave no doubt as to the nature of the 
trouble. 

GLYCOSURIA 

Temporary glycosuria or dietetic glycosuria is of frequent occur- 
rence and little significance. This condition usually means that more 
sugar is being taken than can be cared for by the economy, and with a 
discontinuance of the excessive intake the sugar disappears from the 
urine. 

Illustrative Cases. — In a series of observations made several years ago at the 
Country Branch of the New York Infant Asylum, 10 children were selected for 
high-sugar feeding, and 10 per cent, sugar mixtures were given to those under one 
year of age. Every case showed glycosuria after twenty-four hours of this feeding. 

Two most interesting cases of persistent glycosuria without any other mani- 
festation of illness have been under my observation for the past eighteen years. 
That sugar existed in the urine of both patients was discovered by accident. How 
long the sugar may have been present, we have no means of knowing. The 
mother, an unusually careful woman, conceived the idea that it would be wise to 
have the urine of all her four children examined. It was accordingly sent to me, 
and greatly to my surprise I found that two specimens, one from a boy of four 
years, the other from his brother of six, contained a large amount of sugar — 3 
and 3.5 per cent, respectively. A careful examination was at once made of both 
patients, but revealed nothing abnormal. The children were strong; there was 
no unusual thirst and no polyuria, and, further, the examination of the urine failed 
to reveal the presence of either acetone or diacetic acid. They were placed on a 
rigid antidiabetic diet (p. 737), which reduced the sugar to 1.5 and 2 per cent, 
respectively. During the eighteen years that have since intervened the boys have 
made satisfactory physical and mental progress; they have attended school 
regularly, except when prevented by the usual ailments of childhood. Both have 
undergone operation for adenoids and enlarged tonsils, under ether anesthesia, 
with no more than the usual discomfort. They have made normal increase in 
stature, weight, and strength, and are perfectly normal in appearance. During 
these years monthly examinations have been made of the urine. There has never 
been less than 1.5 per cent, of sugar in any specimen. The sugar has rarely been 
below 3 per cent, or above 6 per cent. The condition has persisted in spite of the 
most careful diet. There never has been polyuria or extreme thirst. The children 
have been seen by several consultants in New York City, and have been under 
the treatment of three well-known specialists in Germany. Recently acetone 



438 THE PEACTTCE OF PEDIATRICS 

has been found in the urine of one. Probably every variety of treatment which 
might be expected to exert an influence on the sugar-production has been tried for 
protracted periods without exerting a particle of influence in reducing it. Indis- 
cretions in diet increase the sugar; otherwise it varies as stated above. 

The cases here cited in detail are of much interest as showing the in- 
efficiency of medication and the effects of diet in glycosuria, and, fur- 
thermore, as presenting a clinical picture which is most unusual. It 
has been suggested that the glycosuria in these cases may be due to 
some persistent and unusual toxemia from intestinal sources. 



The Kidneys 
tuberculosis of the kidney 

Tuberculosis of the kidney is usually secondary to tuberculosis 
existing elsewhere in the body. Primary cases, however, have been 
reported. 

Lesions. — In general tuberculosis miliary tubercles are scattered 
throughout the kidney. In other forms there are nodular lesions, or 
foci of caseation which may break down, resulting in the formation of 
cavities. 

Symptoms. — The symptoms of the disease are progressive weakness 
and emaciation, attended by a low grade of fever. In many instances 
the affected kidney is enlarged and palpable. Frequency of urination 
is a characteristic symptom, and the urine may contain albumin, 
blood, or pus. The presence of blood for a considerable period in 
urine of normal specific gravity containing no casts is strongly suggest- 
ive of tuberculosis of the. kidney. The finding of the tubercle bacillus 
in the centrifuged urine substantiates the diagnosis. Catheterization 
of the ureter is of value in demonstrating whether one or both kidneys 
are involved. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — Tuberculin therapy, in careful hands, may be of value. 
In all cases the routine supportive treatment followed in other forms 
of tuberculosis should be employed. When one kidney remains normal, 
the best results are gained by surgery involving extirpation of the 
diseased organ. 

NEW -GROWTHS OF THE KIDNEY 

Non-malignant. — Non-malignant new-growths of the kidney are 
uncommon. Adenomata and fibromata are occasionally encountered. 
The adenomata are either papillary or cystic, and are encapsulated by 
connective tissue. These growths appear as small, Hght-colored nod- 
ules, and, microscopically, present an alveolar or tubular structure. 
Fibromata exist as white, nodular masses, usually not over }i inch 
in diameter. They are imperfectly differentiated from the interstitial 
connective tissue of the kidney. 



HYDRONEPHROSIS AND PYONEPHROSIS 439 

Malignant. — Adenosarcomata and adenocarcinomata are two forms 
described in the literature. Herringham* emphasizes the fact that the 
degree of malignancy of such growths cannot be accurately determined 
from their histologic structure. 

MaHgnant neoplasms of the kidney are more common before the 
fifth year of life than in any succeeding decade, f These tumors have 
been classified as carcinomata and sarcomata. Most of the growths, 
however, are atypical mixed tumors of embryonic origin, and may con- 
tain striped muscle, cartilage, and lipomatous or fibrous connective 
tissue. 

The hypernephroma is derived from suprarenal tissue, which may be 
included in the developing kidney. This tumor is subject to great 
variations in size and structure, and may resemble sarcoma, adenoma, 
carcinoma, or peritheUoma. The growth characteristically contains 
pigment, which is indentical with that found in the adrenal. Not in- 
frequently the hypernephroma becomes cystic. 

Symptoms of Renal Neoplasms. — Malignant growths of the kidney 
often attain an enormous size, haK fiUing the abdominal cavity and 
displacing certain of the contained organs. The abnormal mass is 
usually movable and occasionally communicates pulsations from the 
subjacent aorta. The edges of the tumor are more rounded than 
those of an enlarged spleen or liver, and the anterior surface is less 
closely related to the ribs. Apart from the local physical signs, the 
patient may present no significant symptoms. Nutrition, however, 
is generally impaired, and in many instances the tumor occasions 
dragging pain and hematuria. 

Prognosis. — In untreated cases the course of the disease is pro- 
gressive and its outcome fatal. Metastases, however, are of relatively 
slow development, and are preceded by involvement of the veins closely 
related to the growth. 

Treatment. — Nephrectomy is the only treatment of value, and even 
this is useless when multiple metastases have occurred. 

The majority of the cases which undergo operation develop malig- 
nancy in the remaining kidney within a year or so after the operation. 
A very exceptional case was that of a two-year-old girl, a patient at the 
Babies' Hospital in New York City. From this child Dr. Robert 
Abbe removed a large kidney sarcoma. The recovery was complete, 
and the patient is now a perfectly well young woman, twenty-eight 
years of age. 

HYDRONEPHROSIS AND PYONEPHROSIS 

Hydronephrosis is a condition characterized by distention of the 
pelvis of the kidney with an accumulation of urine. With an invasion 
of the contained urine by the colon bacillus or other pathogenic organ- 
isms, a pyonephrosis develops. 

* Kidney Diseases, 1912, p. 309. 
' t Herringham on Statistics of Morris, Kidney Diseases, p. 311. 



440 THE PRACTICE OF PEDIATRICS 

Etiology. — A few cases of traumatic hydronephrosis have been 
reported. Ordinarily, however, the disease develops as the result of 
some obstruction in the urinary tract which may be either congenital 
or acquired. 

Congenital hydronephrosis may be due to an angular junction of 
the ureter with the pelvis of the kidney, septa or valves in the ureter, 
an abnormally small ureterovesical orifice, twisting of the ureter by a 
floating kidney, or an imperforate urethra. 

Acquired hydronephrosis may be occasioned by inflammatory 
stricture of the ureter, an obstructing calculus, or external pressure on 
the ureter by a neighboring tumor. 

Pathology. — The ureter is dilated and perhaps sacculated above the 
site of the obstruction. The kidney is usually, but not invariably, en- 
larged, and on section the organ will be found to be structurally 
deficient and more or less cirrhotic. The contained fluid resembles 
normal urine, but contains a relatively small amount of urea. In 
long-standing cases the kidney may become infected and undergo 
suppurative inflammation. In such instances the fluid contents be- 
come purulent and the condition resolves itself into pyonephrosis. 
In fact, in all my cases which came to autopsy — 3 in number — a 
pyonephrosis was present. Usually one kidney only is involved. In 
two of my cases both organs were affected, the pelvis being so dilated 
as to be almost unrecognizable. In a newly born babe who died in 
five days both kidneys were enlarged, soft, and easily palpable. 

Chronic diffuse nephritis is frequently associated with hydro- 
nephrosis. 

Symptoms. — The significant manifestations of '' dropsy of the kid- 
ney" are localized pain and tenderness, a fluid tumor in the kidney 
region, and scanty urination, which may be interrupted at intervals by 
the discharge of urine of low gravity in more than normal amount. 
In doubtful cases aspiration of the fluid from the tumor may facilitate 
the diagnosis. Pus is usually present in the urine, and through cultures 
the nature of the infection may be learned. 

Prognosis. — Children suffering from bilateral hydronephrosis die 
in early infancy. When the condition is unilateral, the patient may 
survive, provided the unaffected kidney is in other respects normal. 

Treatment. — Prophylactic doses of urotropin have been adminis- 
tered to forestall possible suppuration. Surgery, however, offers the 
best possibilities, and the only operation of permanent value is 
nephrectomy. 

Illustrative Case. — A recent case presented very puzzling symptoms. There 
was a periodic discharge of large amounts of urine, containing free pus, casts, and 
epithelial cells. The phenomenon occurred about every second or third day. 
Between times specimens of the urine obtained by catheter were normal. The 
child died from malnutrition and marasmus. At autopsy one kidney was found 
normal. The other showed a typical dilated hydropyonephrosis, with the upper 
two-thirds of the ureter dilated, sacculated, and thickened. In the lower portion 
there was a congenital constriction with angulation which gave way when the pres- 
sure from above became pronounced and the kidney contents were evacuated. 



ACUTE PARENCHYMATOUS NEPHRITIS 441 

CYSTS OF THE KIDNEY 

Cysts of the kidney are usually congenital, due to defective embry- 
onic development. These cysts occur in that portion of the organ 
which is developed from the metanephros. They are almost always 
bilateral, and are usually associated with a process of fibrosis which 
replaces a variable amount of the parenchyma of the affected organ. 
In many of the patients other congenital malformations coexist. 

Retention cysts occasionally arise from obstruction along the 
courses of the uriniferous tubules, and secondary cystic degeneration 
may be induced in a kidney which is the seat of a destructive primary 
disease. Hydatid cysts develop occasionally as the result of echino- 
coccus invasion. 

Many infants with congenital cysts of the kidney die in the first 
year of life. 

Symptoms of the diseased condition are unapparent, or else are 
confined to the local signs of tumor, and such manifestations of urinary 
retention as edema and uremic convulsions. Wyeth states that it is a 
safe rule to aspirate the contents of a renal tumor which is large enough 
to be appreciated by palpation and inspection. If this be done, the 
fluid from congenital cysts will be found to resemble that from a hydro- 
nephrosis, that from a hydatid cyst will show the presence of booklets, 
and that from an organ undergoing cystic degeneration will be found 
to be highly albuminous. 

When treatment of cyst of the kidney is justifiable, the procedure 
must be surgical. 

ACUTE PARENCHYMATOUS NEPHRITIS (ACUTE DIFFUSE NEPHRITIS) 

Nephritis, in common with many other ailments of children, may 
be either mild or severe. It may be so severe as to cause death in a few 
hours, or so mild as to pass unrecognized. In cases often classed as 
primary, nephritis probably is the sequel of unrecognized scarlet fever. 
I have seen but three apparently primary cases in young infants three 
and four months of age, in whom no previous disease had existed. 
All were institution children, and all the cases came to autopsy. 

Etiology. — In an immense majority of cases acute nephritis occurs 
as a complication of the acute infectious diseases. Nephritis is more 
frequently associated with scarlet fever than with any other ailment of 
childhood. I have observed nephritis complicating scarlet fever, 
diphtheria, parotiditis, measles, malaria, influenza, varicella, general 
sepsis, and acute intestinal infection. 

Effects of Different Toxic Agents. — Acute inflammation of the kid- 
neys is caused by chemical or bacterial irritants. In the course of 
any local or general infection, toxins or bacteria, or both, are excreted 
by the kidneys, and may cause degeneration or inflammation of 
these organs. Thus pneumococci may be isolated from the urine in the 
course of a nephritis complicating pneumonia, typhoid bacilli during 
typhoid fever, and streptococci during any streptococcal infection. 



442 THE PRACTICE OF PEDIATRICS 

The bacteria are also found in the kidney at autopsy. The diphtheria 
toxin, and not the bacillus itself, is the cause of post-diphtheric 
nephritis. 

Suppurative inflammation of the kidney may be of hematogenous 
origin, due to any one form of the pyogenic cocci, or it may be caused 
by an ascending inflammation from the bladder, ureter, and pelvis of 
the kidney. The latter condition is a pyelonephritis, and its almost 
invariable cause is B. coli communis. 

Pathology. — The changes which occur in the kidney may be pre^ 
dominantly exudative or productive in character, and may effect the 
parenchyma most severely, or be fairly well limited to the interstitial 
tissue. 

In ordinary acute nephritis of the parenchymatous type the organ is 
enlarged, of decreased consistence, and on section presents a dull gray 
cortex the capsule of which strips easily. There is more deeply con- 
gested medulla. Structural markings are obscured, although occa- 
sionally the glomeruli stand out on the cut surface as scattered reddish 
spots. Microscopically, the parenchyma is found to be the seat of 
granular degeneration and exfoliation, so that the tubules have become 
dilated with necrotic cell-products, casts, and free blood-corpuscles, the 
amount of blood depending on the degree of congestion in the vessels 
of the glomeruli. The kidney stroma is edematous and may show 
considerable cellular infiltration and proliferation. Proliferation of the 
cells lining the capsule of Bowman is also common. 

Shennan states that the degenerative changes in the kidney depend 
on the nature of the causative toxin and its concentration, some toxins 
producing chiefly catarrhal changes, while others cause cell necrosis. 
The urine under the conditions described, although decreased in amount 
and containing albumin and casts, may, nevertheless, be of low specific 
gravity, due to diminished excretion of urea. 

In acute nephritis of the interstitial type, which is much less frequent, 
the urine may be free from pus, casts, and albumin. More often, how- 
ever, this condition does not obtain, as the nephritis is secondary to a 
general pyemia or part of an ascending pyelonephritis, in which case the 
tubules microscopically show evidences of marked degeneration in 
addition to the more apparent process, an infiltration of the connective 
tissue with polynuclear cells. 

In a late nephritis of the interstitial type the development of 
fibrous tissue with atrophic changes in the glomeruli may possibly 
render the diseased organ smaller and firmer instead of larger and 
softer then normal. 

In the typical diseased kidney of scarlet fever there is a very char- 
acteristic glomerular nephritis, marked by a proliferation of the 
epithelial and endothelial cells lining the capsules and on the tufts, and 
by an extensive round-cell infiltration of the tissue about the glomeruli. 
A severe attack of renal congestion during the febrile period of scarlet 
fever does not ordinarily become chronic; but a glomerulonephritis, 
slow in onset and of the productive type, may cause death from acute 



ACUTE PARENCHYMATOUS NEPHRITIS 443 

suppression of urine during convalescence, or perhaps terminate in 
chronic nephritis. 

Time of Development. — Nephritis may develop at any time during 
the active stage of scarlet fever. It is rare before the third week, and 
it may be delayed for several weeks after. Cases not infrequently 
develop after the sixth week. I have known the nephritis to appear 
as late as three months after the acute symptoms of the primary 
disease have subsided. The severity of scarlet fever bears but little 
relation to the development of nephritis or the time of such develop- 
ment. In consultation practice a previously undiagnosed illness, 
with rash or stomach disturbance, has been determined as having 
been scarlet fever by the development of nephritis at a considerably 
later date. 

Symptoms. — The disease may exist, run a mild course, and termi- 
nate favorably without symptoms. That this occurs in many in- 
stances is beyond doubt. 

Usually the first symptom noticed is a slight pufl&ness (not edema) 
about the eyes. A similar puffiness of the fingers and the ankles occurs, 
and the backs of the hands, as well as the ankles, soon become edema- 
tous. The skin becomes pale and of peculiar waxy whiteness. The 
patient exhibits loss of appetite and nausea, and sometimes vomits. 
Mild frontal headache is a frequent symptom. As the case pro- 
gresses the peculiar pallor increases, the face becomes very much swollen, 
the eyes almost close, and the legs and "the feet increase very much in 
size and have a cushion-like appearance and consistence. The sub- 
cutaneous tissue over the back and abdomen becomes infiltrated, and 
the whole aspect of the body is changed. There is a smoothing out 
of the folds and angles, giving a decidedly rotund appearance. As the 
result of such a general edema the child increases very much in weight. 
A child weighing 40 pounds will increase in weight one-third. 1 
have seen an increase of 15 to 20 pounds in not a few cases. 

In children one would invariably look for the more active symp- 
toms, headache, vomiting, and prostration, but in many instances 
these symptoms are not prominent. 

Fever. — An elevation of temperature usually exists in all cases, but 
it is not necessarily high. Although a fever of 103° to 105°J. is of 
occasional occurrence, the usual temperature range is from 100° to 
103°F. The temperature, as a rule, is not of long duration unless the 
case is to have a fatal termination. I look upon a high continuous 
temperature as an unfavorable sign. 

The Urine. — In every case of scarlet fever — in fact, in aU infectious 
diseases — the urine should be examined daily, as recommended under 
the subject of management. Time and again 1 have known cases show- 
ing a moderate amount of albumin and casts, with a few blood-cells, to 
clear up entirely under treatment. If these cases are not recognized 
and properly treated, a large proportion go on to develop the more 
serious characteristic signs of the disease. 

The first objective sign will be scantiness of the excretion of urine. 



444 THE PRACTICE OF PEDIATRICS 

The urine voided will be reduced from a total quantity of 30 to 40 
ounces to only 10 to 15 ounces. Later a very few ounces only may be 
excreted, or the urine may be completely suppressed (anuria). 

The color becomes very dark, and if blood is present, the urine will 
show a decidedly smoky appearance. Blood may be present in such 
large amounts as to give the appearance of pure blood. 

Uremia, — In very severe cases uremic convulsions may occur. 
Severe headache and repeated vomiting, with scanty urine and de- 
ficient excretion of urea, are indications that uremia exists. 

Convulsions. — The convulsion comes on suddenly and is bilateral. 
It may last but a few minutes, or it may last for several hours. The 
child may die in convulsions. 

Fulminating Cases. — A form of acute nephritis which deserves 
particular attention occurs early in malignant scarlet fever. The 
onset is very abrupt. But little urine is passed, and this is filled with 
albumin, casts, and blood. 

Illustrative Case. — In a recent case complete suppression occurred without pre- 
vious warning, and the child died in thirty-six hours, the duration of the entire 
illness being but seventy-two hours. There was no edema. The child became 
comatose, and died from the uremia and the intense scarlatinal poisoning. 

Duration. — The duration of an attack depends largely upon the 
severity. Thus I have had cases well in one week, and others in which 
the urine was not free from albumin and casts for six weeks and some- 
times longer. In case of apparent recovery I do not look upon the 
patient as fully recovered until twelve months have elapsed. I never 
allow a child who has had well-marked nephritis to pass from my 
observation within less than one year. A peculiarity of nephritis is 
its tendency to return. The chronic cases which we see, both in 
private and in hospital work, almost invariably give a history of two 
or more acute attacks, at intervals perhaps of several months. The 
second and subsequent attacks might have been prevented by proper 
protection and care. 

It may, therefore, be put down as a fact that chronic nephritis in a 
child often means neglect, as much on the part of the family as on the 
part of the physician. 

Prognosis. — The prognosis of severe acute nephritis is good if 
proper management is carried out from the beginning of the illness 
until at least one year has elapsed. The prognosis is bad in even a mild 
case if it is neglected. Nephritis is one of the diseases in which right 
management is most essential, even in very mild cases. 

Diagnosis. — That nephritis is present is indicated by the appear- 
ance of swelling about the eyes and ankles, or by a more active onset of 
vomiting, fever, and headache. 

Suspicion in any given case may be easily verified by a urine 
examination. 

Examination of Urine. — If, during scarlet fever or any of the infec- 
tious diseases, the physician takes the precaution of having nitric acid 
and a few test-tubes at the home of the patient so that the urine may be 



ACUTE PARENCHYMATOUS NEPHRITIS 445 

tested for albumin at each visit, in addition to a reasonably frequent 
microscopic examination at his office, a nephritis may be detected 
before the more active clinical signs of the disease appear; and thus, 
by placing the patient promptly under suitable management, usually 
but httle trouble will be experienced. 

Treatment. — The treatment of nephritis, reflecting as it does the 
present methods of schools, in their advocacy of forced, indiscriminate 
water-drinking, the exclusive milk diet, and the more or less indis- 
criminate use of diuretic drugs, is often open to the most emphatic 
criticism. Even one of these measures is capable of, and has been 
productive of, no little harm. Too great emphasis has been placed 
upon forcing the kidneys to act, and too little upon the necessity of 
relieving them of the work for which they are temporarily incapaci- 
tated. The advocacy of drinking large amounts of water when the 
kidney blood-vessels are distended, the tubules are obstructed, and 
the parenchyma is secreting but very little, does nothing but harm. 
Under such conditions heart stimulants, such as digitalis, which 
forces more blood into the kidneys, necessarily make a bad matter 
worse. 

General Management. — In treating nephritis there are several factors 
to be kept in mind. Because a case is mild it should never be given 
scant attention. Nephritis in a child may be most insidious in its 
course. The mildest case, while not treated in all respects like a more 
severe one, should be given every possible attention relating to rest 
in bed and diet ; for through neglect, even for a very few hours, a mild 
case may become most severe. 

A child with nephritis must be kept in bed with the temperature of 
the room at about 70°F. He should be protected from drafts of cold 
air. Silk, a mixture of silk and wool, or flannel should be worn next to 
the skin. 

Diet. — The nutrition of the patient is to be maintained by food 
which will not add to the existing trouble. We are told that nitrogen- 
ous food, such as meats and eggs, is to be avoided in order to relieve 
the kidneys from the work of excretion of urea and creatinin ; and yet, 
often we are advised in the very next line to give a full milk diet, 
which, in the case of a child from five to ten j^ears of age, means from 
two and one-half to three quarts daily. Milk, it will be remembered, 
contains 4 per cent, of nitrogenous food, necessitating that large amounts 
of nitrogenous waste by-products be excreted by the kidneys. 

In order to maintain the nutrition of the patient, proteid is neces- 
sary, and may be supplied by the use of a moderate amount of milk. 
To a child from five to ten years of age, from 16 to 20 ounces of full 
milk should be given daily — never more than 20 ounces. This should 
be diluted with equal parts of cereal gruel. No. 1 or 2, with the 
addition of one teaspoonful of sugar (see formulary, p. 70), and 
given in quantities from 6 to 10 ounces at four-hour intervals. The 
taste of the food may be changed by the use of cereal gruels of differ- 
ent kinds. Zwieback and butter, stale bread and butter, prune-juice, 



446 THE PRACTICE OF PEDIATRICS 

simple fruit jelly, thin apple-sauce, and orange-juice may be given in 
order to improve the digestion and add variety to the diet. Inas- 
much as milk and fruit cannot be taken simultaneously by many 
patients, the fruit may be given between meals or with a plain meal 
gruel, and thus increase the nutritive value of the daily ration. Broths 
and beef extracts are not to be given because of their creatinin content. 

The Salt-free Diet. — The value of a salt-free diet in nephritis is now 
very generally recognized. The rationale underlying this treatment 
has been concisely set forth by L. Miller, who, after reviewing the work 
of Widal, Javal, and other observers, states the following conclusions: 

*'In patients with moderately severe nephritis associated with 
edema the ingestion of large amounts of sodium chlorid is followed by 
chlorid retention. The patient gains in weight, the edema becomes 
more marked, the albuminuria increases, and symptoms may develop 
resembling uremia. 

*'In patients with very severe nephritis, and especially those with 
uremia, chlorid retention is very marked, as scarcely any of the extra 
chlorid administered is eliminated. 

"In individuals with apparently healthy kidneys, following the 
ingestion of sodium chlorid there is a chlorid retention equal to that of 
a mild nephritis. The individual gains in weight, but there is no 
visible edema, no albuminuria, and no uremic symptoms." 

The degree to which defective kidney excretion is responsible for the 
edema of nephritis is still in doubt, but it is certain that exclusion of 
common salt from the food, including even such substances as bread, 
is frequently followed by marked improvement, which ceases on a 
return to the salt-containing diet. 

Bowel Evacuation. — A patient with nephritis, no matter how mild, 
should have two bowel evacuations daily. These should be rather 
loose. Ths use of the fruit-juices may be sufficient to keep the bowels 
relaxed. If a laxative is necessary citrate of magnesia, or, for very 
young children and infants, milk of magnesia, may be given in such 
doses and at such intervals as may be necessary to produce the desired 
results. The patient should always have an enema at bedtime if no 
passage has taken place during the preceding twenty-four hours. 

Bath. — A warm sponge-bath should be administered daily, the pa- 
tient being sponged and dried part by part under a flannel blanket. 

Treatment of Severe Cases. — When there is fever with partial sup- 
pression of the urine, only one-half the usual quantity being passed, 
and that loaded with albumin, blood, and casts, with perhaps beginning 
edema, colon flushings (p. 795) with a normal salt solution at a tem- 
perature of 110°F. are to be used. The flushings have the effect of 
increasing the functional activity of the kidneys. For a child from five 
to ten years of age one pint of the warm saline solution may be thrown 
into the colon. An effort should be made to have the child retain the 
fluid by resting on the left side with the buttocks elevated on a pillow. 
For young children from eight to twelve ounces may be used. Infants 
under nine months may retain only four to six ounces. The flushings 



ACUTE PARENCHYMATOUS NEPHRITIS 447 

should not be repeated oftener than at twelve-hour intervals, unless 
the condition is urgent, as intolerance of the parts is readily brought 
about by too frequent manipulations. 

If the skin is hot and dry and the temperature tends to remain above 
102°F., tincture of aconite may be given in small doses. To a child 
three years of age, one-half drop may be given at two-hour intervals. 
Older children may be given one drop at a dose. It is rarely wise to in- 
crease the amount above two drops at two-hour intervals even for 
children above ten years of age. Only sufficient aconite should be 
given to produce a slight diaphoresis, for when the skin is kept con- 
stantly moist, the blood-vessels of the kidneys are relieved of the tension 
to which they have been subjected. 

In the severer cases, with edema or anasarca, in which but two or 
three ounces of urine are passed daily, more active measures will be 
required. In these urgent cases the diet should consist temporarily 
of thin gruels of barley, granum, or rice (No. 1), with sugar added to 
make them more palatable, and diluted fruit-juices given between 
the feedings. In a carbohydrate diet there are no by-products irri- 
tating to the kidney. Water should be given scantily, sufficient fluids 
being given in the food. Active measures to increase diaphoresis and 
thus relieve the kidneys must be instituted. The best method of do- 
ing this is by the use of hot colon flushings, hot packs, hot baths, and 
hot flaxseed poultices. In these severe cases the use of digitalis and 
alkaline diuretics does an immense amount of harm. Digitalis drives 
more blood into the kidneys and thus increases the congestion. The 
alkaline diuretics disturb the stomach, which is already showing signs 
of food intolerance. Colon flushings (p. 795) at 110°F. are to be used 
every six hours. This is probably one of the most valuable means we 
possess for relieving the congestion of the kidney and inducing a flow 
of urine. 

Local Application of Heat — Heat, either dry or moist, should be 
immediately employed in order to stimulate the skin to vigorous action. 
Dry heat and moist heat each has its advocates. Keeping the child 
in a warm bath at 105°F. for a few minutes, drying rapidly, and 
immediately putting him into bed, surrounded by hot-water bottles, 
will usually produce diaphoresis. A thermometer should be placed 
under the bed-clothing so that excessive heat may readily be detected. 
I have seen pronounced weakness produced by the use of excessive heat. 
The child should not be allowed to rest in a temperature higher than 
120°F., and heat of this degree should not be maintained over ten 
minutes. A temperature of 105°F. or 110°F. may be maintained for 
an hour if necessary. If the pack is used, it may be repeated once in 
six hours. The disadvantages of a hot bath are due to the fact that 
it necessitates considerable handling, which to some patients is a cause 
of no little excitement. In such cases dry heat may be substituted, 
the patient being warmly clad in flannels, while hot-water bottles are 
placed near his body. This may be sufficient to induce perspiration. 
A device which I use consists of a funnel attached to a one-inch brass 



448 THE PRACTICE OF PEDIATRICS 

pipe, which is bent in the middle to a right angle and which conducts 
the warm air under the bed-clothing. The heat is generated by a kero- 
sene lamp, over the top of which the inverted funnel is placed at a 
sufficient distance to allow combustion to take place. 

In some cases I have had satisfactory results from the use of hot 
flaxseed poultices made very large, 6 or 10 inches wide and 2 inches 
thick, and sufficiently long to entirely envelop the abdomen. These 
are to be applied as hot as can be borne at about twenty-minute in- 
tervals for one hour, and repeated again in three hours. This inter- 
rupted use of the poultices has been continued as long as nine days, 
with most marked benefit, both in private and hospital cases. 

The Murphy drip may also be used, but it has not proved very suc- 
cessful. The pressure of the tube in the bowel for the long time re- 
quired is not borne well by children, and occasions a great deal of 
restlessness and irritability. I apply this means only in extreme con- 
ditions, in which the child's state is such that he is not annoyed. 

While a free secretion of urine is desired in these cases, we must not 
be content with that alone. Uremia my occur even while the normal 
amount of urine is being passed. A quantitative test for urea should 
be made in all severe cases in order to determine the amount excreted. 
Normal urine, in children, contains approximately 2 per cent, of urea, 
which in health occasionally rises to 3 per cent. Approximately 0.5 
gram of urea is excreted per kilogram of body-weight. The proportion 
in children is relatively higher.* 

Amount of Urea Excreted on the Basis of 0.5 Gram per Kilogram 

in 24 hrs. 



lyear i Qirls 8.24t 4.12 gm. 

Svears / Boys 14.14 7.07 gm. 

d years | Qirls 13.60t 6.80 gm. 

Boys 22.44 11.22 gm. 

Girls 21. 78t 10.89 gm. 

Boys 30.22 15.11 gm. 

Girls 29.07t 14.535 gm. 

Boys 40.04 20.02 gm. 

Girls 41. 36t 20.68 gm. 

Boys 56.09 28.045 gm. 

Girls 51. 24t 25.62 gm. 



7 years 
10 years 
13 years 
16 years 



n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 
n 24 hrs. 



Treatment of Uremic Convulsions. — Vomiting is one of the first 
symptoms of uremia. When it occurs, all food should be temporarily 
withheld from the stomach and nutrient enemata given. Completely 
peptonized skimmed milk is our best means of nutrition, from 4 to 12 
ounces being given every four to six hours. It is best to give the larger 
quantity at the longer interval, — every six hours is best, — as the 
manipulations with the tube have a tendency to produce intolerance 
on the part of the gut. The tube should be introduced at least eight 
inches into the bowel and the solution used should be lukewarm. 

* R. Bradford, in Allbutt's System of Medicine, 
t Figures of Boas, quoted from Holt. 



CHRONIC DIFFUSE NEPHRITIS 449 

Fluid at a temperature of 95° or 100°F. will best be retained. In 
addition to the use of colon flushings and external heat in the form 
of the flaxseed poultices referred to, uremic convulsions should be 
controlled with chloroform or the rectal administration of the bromids 
or chloral. To a child under three years of age, 2 grains of chloral 
may be given with 8 grains of bromid of soda. After the third year, 
3 grains of chloral may be used with 8 to 15 grains of bromid of soda. 
This medicine is best retained when given in at least 4 ounces of 
mucilage of acacia or skimmed milk, the enema being repeated in 
four to six hours. 

When heart stimulants are required, tincture of strophanthus is 
usually given — one or two drops at two-hour intervals to a child 
under three years of age. After this age two or three drops may be 
given. Digitalis is sometimes used as a heart stimulant during con- 
valescence, after the secretion of the urine has been established. 

Convalescence. — Convalescence is often tedious in these cases. 
The child should not be allowed to be out of bed until albumin has 
disappeared from the urine. For at least six months after an attack 
the urine should be examined weekly. Light-weight woolens should 
be worn next to the skin during the entire year, and every effort made 
to protect the patient from sudden exposure to the influence of cold air. 
Upon the advent of any subsequent illness with fever, even though it 
should not occur for a year or two afterward, unusual precautions should 
be taken to protect the child, in view of a possible rein vol vement of the 
kidneys, with, possibly, a resulting chronic nephritis. Meat and eggs 
should be given scantily for a year after the attack. Exercise calling 
for more than ordinary muscular effort should not be allowed for at 
least a year after all trace of the nephritis has disappeared. I advise, 
when possible, that the winter after an acute attack be spent in a warm 
climate, such as that of Florida or Lower California. 

CHRONIC DIFFUSE NEPHRITIS 

This disease is rarely seen in children under three years of age. I 
see a goodly number of cases every year in children from the fifth to 
the twelfth year of age. 

Nephritis of this type is almost invariably the result of an acute 
process which has run its course unrecognized or of faulty management 
following acute nephritis. A patient who came under my care three 
years ago with chronic nephritis gave a history of having had three 
distinct acute attacks during the previous four years, with intervals 
of apparent health. The urine had not been examined during these 
intervals nor had she had the advantages of proper treatment. Such a 
history is quite usual. 

Pathology. — In chronic parenchymatous nephritis (chronic diffuse 

nephritis without marked interstitial changes) the kidney is enlarged, 

pale, and of decreased consistence. The capsule strips easily, and the 

cortex, on section, is found to be wider than normal, and frequently 

29 



450 THE PRACTICE OF PEDIATRICS 

of a light yellowish hue. The most pronounced microscopic changes 
are those found in the tubules, the epithelium of which undergoes a 
variable amount of granular and fatty degeneration and exfoliation. 
The glomeruli also may show hyaline changes, swelling, and cellular 
proliferation and desquamation. In some cases the disease is pre- 
dominantly a chronic glomerular nephritis. Interstitial changes are 
not, as a rule, important. The urine may be cloudy, is usually of in- 
creased specific gravity, and contains albumin in variable amount, 
leukocytes, epithelial cells of renal origin, hyaline and granular casts, 
and occasionally red corpuscles. 

Symptoms. — Chronic nephritis rarely develops insidiously as in 
the adult. Usually it is a continuation of the second, third, or fourth 
acute exacerbation. Instead of subsiding, the edema and the pallor 
remain pronounced, and the abnormal urinary findings persist. 

Anemia is always present, and, as the condition progresses, digest- 
ive disturbances become manifest. The appetite is usually indiffer- 
ent, and commonly there is vomiting. Other symptoms are marked 
edema and drowsiness. The progress of the disease is variable. There 
are periods when recovery seems at hand, and then all the symptoms 
return in an aggravated form. Ascites is usually present in the ad- 
vanced cases. Effusion into the pleural cavity and into the pericar- 
dium may be looked for. Pulmonary edema is a constant symptom 
a few days or hours before a fatal termination, if uremic convulsions 
are delayed. 

Prognosis. — The patients are always the subjects of much sohci- 
tude. My results have not been brilliant. In some of my cases the 
illness began after an infectious disease, usually scarlet fever, and ran 
a slowly progressive course, which under the best of management de- 
fied every effort, terminating fatally in three months to a year. In 
other cases improvement occurred, casts and albumin disappeared 
from the urine, and the child was apparently well. 

Exacerbation. — Even in favorable cases, however, — as the result of 
exposure, some intercurrent disease, or some unknown cause, — an ex- 
acerbation occurs, and the attack is repeated, usually in graver form 
than the previous one. The urine becomes scanty and loaded with 
albumin and casts, the child becomes edematous and pale. Treat- 
ment may perhaps relieve the condition, but this attack is followed by 
another in three to six months, after an interval of apparent health. 

Illustrative Cases. — In one girl four years old five distinct recurrences took place 
before death, which occurred in the fifth attack. 

A girl nine years old gave a history of chronic nephritis lasting two years. She 
made a complete recovery — at least there has been no recurrence in seven years. 

A boy aged four remained well for two years after an illness covering six months. 
After this period he passed from my observation. 

Diagnosis. — The diagnosis is confirmed by repeated urine examina- 
tions. Albumin and casts may be present for a considerable period 
without other signs than anemia. The anemia, with puffiness about 
the eyes and swelling of the feet and ankles, is a most suggestive sign. 



CHRONIC DIFFUSE NEPHRITIS 



451 



Treatment. — The management of chronic diffuse nephritis of only 
moderately severe type is to be considered with respect to four factors : 
diet, baths, exercise, and climate. 

If the patient is confined to bed, the diet should be the same as 
suggested under Acute Nephritis. The food should be largely salt- 
free. Twenty ounces of milk may be given daily. If the child is up 
and about, meat may be given once every second day. Eggs should 
be excluded. In other respects the diet should be simple, as outhned 
for well children (p. 105), this being ample for nutrition. 





Fig. 55. — Chronic nephritis before 
Edebohls operation. 



Fig. 56. — Same case as Fig. 55 after 
Edebohls operation. 



The child should receive one warm bath — 95° to 100°F. — daily, 
followed by brisk friction with a dry towel. 

An outdoor hfe is of decided advantage. Exertion, however, 
should not be allowed to the point of fatigue. Contests or stress of 
any kind, mental or physical, should not be permitted. 

If possible, the child should spend the colder months in a chmate 
which is not subject to sudden or wide variations in temperature. The 
climate furnished by Florida or Lower CaHfornia is advocated when 
the parents are financially able to give the patient this benefit. If, 
however, the patient must be kept in his home, which does not offer 
the advantages of an equable climate, great care should be exercised 
in preventing sudden chilling of the skin surface. Woolens should be 
worn next to the skin at all seasons of the year. Frequent examina- 



452 THE PRACTICE OF PEDIATRICS 

tions of the urine should be made, not only for albumin and casts, but 
for urea as well. Sudden attacks of uremia may occur even while the 
patient is passing an excessive amount of urine. 

The management of suppression and anasarca is very much the 
same as described for these conditions occurring in acute nephritis 
(p. 441). 

Diuretics with which the physician is familiar and in which he has 
faith, may be given well diluted, so as not to disturb the stomach. 
In the severe forms of chronic diffuse nephritis I have yet to see a 
diuretic of the slightest value. 

Illustrative Case. — A three-year-old girl, a patient in the Babies' Hospital in 
my service, presented the typical picture of advanced chronic nephritis (see Fig. 
55). The usual treatment with calomel, salines, colonic flushings, and hot packs 
and diuretics failed to make any impression. The urine presented the usual 
changes and was very scanty. After two weeks of unavailing treatment, during 
which period the child became constantly worse, the Edebohls operation of 
decapsulation of the kidney was performed by Dr. William A. Downes, of New 
York City. The kidney secretion gradually increased — the urine showing but a 
trace of albumin two weeks after the operation. The thirteenth day following the 
operation the child had lost IQ^i pounds in weight and presented the appearance 
seen in Fig. 56. There was an interval of two weeks between the time of taking 
the two photographs. 

During convalescence from the operation, however, the child developed a very 
severe colitis, from which she died six weeks after the operation. I look upon this 
case as a remarkable demonstration of temporary value, at least, of decapsulation 
of the kidney. Unfortunately, the intercurrent colitis terminated life before the 
permanent effects could be determined. 

CHRONIC INTERSTITIAL NEPHRITIS 

Chronic interstitial nephritis is a very rare condition in children. 

Etiology. — The etiology is obscure. A persistent toxemia from in- 
testinal sources is the most logical explanation. 

Syphilis, alcoholism, and the infectious diseases have all been looked 
upon by different authors as possible etiologic agencies. 

Symptoms. — A wide range of symptoms is put down by authors. 
As my personal experience has been so meager, I can do no better 
than recite the symptomatology of a case coming under my observation. 

Illustrative Case. — This boy evidently had suffered from the disease for three or 
four years. There was a history of chronic polyuria, thirst, and enuresis. He was 
very small, very thin, and anemic. He was habitually tired and listless. The skin 
was dry and rough and appeared to be pigmented in spots. There was no sugges- 
tion of dropsy, and the boy had never been known to perspire. He passed from 60 
to 90 ounces of urine daily. The specific gravity was low. The one specimen ex- 
amined by me showed a specific gravity of 1002, no albumin and no casts. Death 
resulted from exhaustion and uremia. 

Treatment. — The management of these cases is symptomatic. 

ORTHOSTATIC ALBUMINURIA 

Albuminuria occurring only during the hours when the upright 
position is maintained is not uncommon in male children after the age 
of six years. Females are less often affected. It has been observed 



PYELOCYSTITIS (PYELITIS) 453 

that while the albuminuria is due to the upright position, lordosis 
contributes especially to its occurrence. 

Symptoms. — Most of the subjects are somewhat anemic and thin 
and suffer in greater or less degree from digestive impairment and 
symptoms of mild toxemia such as headache and irritability. Holt 
states that a degree of lordosis is the rule. The urine excreted while 
the child is at rest in the recumbent position is not abnormal but that 
excreted following assumption and maintenance of the erect position 
contains albumin in varying amounts ranging as high as 50 per cent, 
by volume. Hyaline casts are occasionally found. The substance 
giving the albumin reaction is serum albumin plus probably chondroitin 
sulphuric acid (Holt) which is capable of being precipitated by acetic 
acid in the cold. 

Prognosis. — Orthostatic albuminuria commonly terminates in re- 
covery after the age of puberty. Occasionally the affection persists 
into adult life. 

Treatment. — The principles of treatment essential in cases of 
ordinary malnutrition are to be followed rather than the methods ap- 
phcable to cases of true nephritis. Defects in posture should be reme- 
died by Hght exercises and if necessary by mechanical support. In 
other respects the treatment is mainly that of associated malnutrition, 
anemia and digestive disorder. 

PYELOCYSTITIS (PYELITIS) 

Pyelocystitis is an infection of the bladder and pelvis of the kidney. 
The bladder is probably always involved, and may precede or follow 
the infection of the kidney. 

Sex. — It is a disease of infancy and early childhood, and occurs 
almost uniformh^ in females. I have seen but five cases in males. 

In a case which w^as seen by me late in the illness a pyelonephritis 
had developed which caused the death of the child. The process had 
extended from the pelvis of the kidney to the kidney structure, which 
showed dozens of large and smaU suppurating foci. 

Age. — The majority of the patients are under three years of age. 
Pyehtis may, however, occur at any age. My youngest patient was 
three months of age, the oldest, ten years. It is comparativeh^ rare 
after the fifth year. Its occurrence in female adults does not concern 
us, excepting that it is the belief of not a few^ internists that the disease 
of childhood is carried over to adult hfe. 

Etiology. — The infection, in the great majority of cases, is due to 
the colon bacillus. Anj^ of the pyogenic bacteria, however, which gain 
entrance to the bladder and pass through the ureter to the pelvis of the 
kidney may cause the disease. Thus the staphylococcus, the strepto- 
coccus, the gonococcus, or the typhoid bacillus may be the cause. In 
one of my cases infection was due to the typhoid bacillus; in another, 
to the staphylococcus. I have now seen a large number of cases of 
pyehtis, and with the exception of the one case of typhoid baciUus in- 



454 



THE PRACTICE OF PEDIATRICS 



fection, they were all either preceded by an acute intestinal disturb- 
ance, or occurred independently of any illness. The facility with 
which the infection takes place in girls explains its frequency in the 
female sex. 

I have observed two cases in which there was a bacteriuria, — a 
colon bacillus infection without demonstrable pus, — but with the usual 
clinical signs of pyogenic infection. 

Symptoms. — Pyelocystitis is a disease the chief symptom of which 
is sudden elevation of temperature. That children may have the dis- 
ease without fever cannot be disputed. With or without some slight 
intestinal disturbance there is a sudden rise in temperature from 102° to 
105°F. The rise is usually to the higher point, and is rarely accom- 
panied by a chill. Thomson of Edinburgh believes that a chill in an 
infant is always due to a pyelitis. The temperature ranges between 
101° and 105°F. for three or more days, with remissions to normal. 



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Fig, 57. — Temperature charts — pyelitis. 



During the temperature period the child is fretful and uncomfortable, 
but not particularly prostrated. After the fever has passed the patient 
may appear slightly weak, but she is usually bright and manifests no 
great physical prostration; in fact, there may be no sign whatever of 
illness during the non-febrile period. The disease is often diagnosed 
as indigestion or some trivial ailment, and is forgotten until there is 
again a rise in temperature, which runs a high, irregular, or indifferent 
course for two or more days, and then again subsides. The accom- 
panying chart (Fig. 57) represents an acute case of short duration. 
In a few instances the duration of an individual attack has been not 
more than ten or twelve hours. 

There is usually no pain in these cases, and no unusual frequency 
in urination. Very infrequently a case is encountered in which there 



PYELOCYSTITIS (PYELITIS) 455 

are bearing down and straining during and after urination. Absence 
of both discomfort and frequency of urination leads one to believe 
that cystitis in these cases is probably of a trivial nature. 

The symptom above all others of value in this disease is tempera- 
ture, and when we have distinct temperature periods in girls, such as 
are shown in the chart (Fig. 57) , pyelitis will almost surely be found as 
the cause. 

Diagnosis. — That pyelitis is present is suggested by the presence of 
fever not readily accounted for, in a female infant or young child. 
The diagnosis is verified by the finding of pus in the urine. Pus is not 
found in every specimen of urine voided. Before deciding that pus is 
not present in a given case, at least three specimens should be secured on 
different days. 

For absolutely accurate work a catheterized specimen of urine 
should be secured, particularly if the urine is to be cultured. This is 
not" absolutely necessary, however, in a routine diagnosis. If the child 
is carefully washed before urinating and the urine is caught in a sterile 
vessel, there will not be sufficient contamination to prevent a right 
conclusion. 

Differential Diagnosis. — The diseases most frequently confused 
with pyelocystitis are malaria, typhoid fever, and acute intestinal in- 
fection. The distinct temperature periods and remissions, with days 
of normal temperature, effectually exclude either typhoid or malaria. 
The continuation of the temperature periods, after the intestinal in- 
toxication is relieved, effectually excludes the intestine as the source 
of the fever. Repeated urine examinations confirm or disprove the 
presence of pyelitis. In doubtful cases the catheterized specimen of 
the urine should be cultured. 

Duration. — The duration is variable, and appears to depend more 
upon the time the disease has existed unrecognized than upon the 
nature of the infection. 

A patient in whom the condition is discovered early usually re- 
sponds promptly, and perhaps does not have a second fever period. 
Others in whom the disease has existed for several weeks undiagnosed 
may require several months of treatment. It is not at all unusual for 
a case to continue over two or three months. In one case the disease 
reappeared after an absence of fever and pyuria for three months. In 
another case the disease reappeared after six months and in another 
after eleven months. Whether these cases represent a continuation 
of the old process, or reinfection, it is impossible to say. I am inclined 
to take the latter view. A case should not be pronounced cured under 
six months, even though there is no retiurn of the fever. The urine, 
during this time, should be frequently examined for pus. 

Treatment. — The readiness with which pyehtis responds to treat- 
ment depends considerably upon the duration of the infection. The 
method of treatment which has proven most satisfactory is as follows: 
As soon as the diagnosis is positive, from 60 to 90 grains of citrate of 
potash are given daily in 10-grain doses at two-hour intervals. 



456 THE PRACTICE OF PEDIATRICS 

Sufficient is given to produce alkaline urine. At the end of ten days, 
the potash is discontinued and urotropin given, usually from 16 to 24 
grains daily; again at the end of ten days the potash is resumed. This 
procedure is repeated, alternating the two drugs until the urine is free 
frum pus. The urotropin is effective only when the urine is acid. 

The difficulty that I have experienced has been to obtain sterile 
urine. The fever is usually readily controlled, but pus and bacteria 
remain in the urine over long periods. 

Time Required for a Cure. — The urine should be free from pus for 
a period of at least six months before a case may be pronounced well. 

Vaccine Treatment. — The use of vaccines has not been followed by 
brilliant results. 

The application of this method of treatment to urinary infections 
in children should, therefore, at present be limited to rare cases of gono- 
coccus or staphylococcus origin, and to the very small group remaining, 
which do not respond to medicinal measures. In persistent chronic 
colon cases vaccine may be given a trial. 

I have used both autogenous and stock vaccines in the colon bacillus 
infections and have yet to be impressed with any great value of the 
treatment. I have employed the following procedure and dosage 
without appreciable improvement. Fourteen injections were given 
with one week intervening as follows:— 10,000,000; 20,000,000; 40,- 
000,000; 80,000,000; 200,000,000; 400,000,000; 500,000,000; 500,000,- 
000; 500,000,000; 500,000,000; 600,000,000; 500,000,000; 500,000,000; 
500,000,000. 

PRECOCIOUS MENSTRUATION AND PRECOCIOUS MATURITY 

Precocious menstruation is a physiological anomaly of develop- 
ment (Morse). The usual time for menstruation to begin is between 
the ages of twelve and fifteen years. In some races catamenia begins 
normally as early as nine or ten years. 

There are two distinct types of cases. In one group the precocious 
menstruation is the only symptom, while in the other there is preco- 
cious maturity. The early menstruation is accompanied by the ana- 
tomical changes of puberty. 

The menstruation in the former type of children usually begins 
earlier than in those with precocious development. The average time 
is five years but there have been instances reported where hemorrhages 
begin at birth. The periods last from one to three days and may be 
regular throughout childhood. This is not usual, however, for at times 
for a year or more there may be no signs of menstrual flow. The 
physical and mental development of these children is perfectly normal. 

A private patient, aged nine years, strong and robust, began to men- 
struate at the twenty-first month; very irregular at first, from a few 
weeks to two or three months, but with a fair degree of regularity 
during the past six years. Pubic hair developed at the sixth year and 
the breasts began to develop at the same time. To all outward appear- 



CYSTITIS 457 

ance she is a perfectly normal child, with no signs of early sexual 
development. 

In the second group we are dealing with a profound disturbance of 
development probably due to some derangement of the ductless glands. 
It is a most unusual occurrence. Lenz, in a most exhaustive review in 
1912, was only able to collect 150 cases from the literature. Menstrua- 
tion in these children usually begins early, that is, during the first two 
years and frequently at birth. In 51 cases collected by Morse, 36 
began during the first two years. These patients are usually large 
patients at birth, they have large breasts, axillary and pubic hair and a 
prominent mons veneris. They develop very rapidly and at eight or 
ten years may present the full maturity of the adult. The menstrua- 
tion is regular and preceded esLily in life by various feelings of dis- 
comfort, analogous to those which announce the periods in women. 
There is also an early development of bone as shown by a:-ray. 

That the menstruation in these children is accompanied by ovula- 
tion has been proved by autopsy and there are 11 cases in the litera- 
ture where pregnancy has developed in childhood. One case reported 
began to menstruate at two years, became pregnant at eight years and 
ceased to flow at twenty-five years, and lived to be seventy-five 
without recurrence. 

Etiology. — The etiology of this condition is obscure but there are 
facts which seem to indicate that it is a disturbance of the somatic 
glands. There have been instances reported where the abnormal de- 
velopment has ceased and even retrogressed after the removal of cystic 
tumors of the ovar3^ 

These children should be kept apart from other children. Their 
early modesty sense should be respected. 

The Bladder 

CYSTITIS 

Cystitis in boys is very unusual. In girls it occurs frequently. 
It is not of infrequent occurrence in hospital work. 

Etiology. — The most common bacteriologic agent in the causation 
of cystitis is B. coli communis; next in order of frequency is B. proteus. 
The presence of these intestinal bacteria is explained by the fact that 
intestinal disease usually precedes cystitis in children. 

Streptococci and staphylococci have been found in the urine in 
cystitis. Gonorrheal cystitis in children is extremely rare, and tuber- 
culous inflammation of the bladder is uncommon, even in older children. 

Symptoms. — Frequent calls for urination constitute the most usual 
symptom; so urgent is the desire to void the urine that the child may 
be unable to reach in time a place suitable for the discharge. Incon- 
tinence by day and night is usual in children with only a mild degree of 
bladder involvement. There is, ordinarily, but little pain attending 
urination. Sometimes there is evidence of distress at the completion 
of the act, but this is unusual. Inability voluntarily to control the 



458 • THE PRACTICE OF PEDIATRICS 

urine during the day, extending over a considerable period of time, 
points to bladder involvement due either to the presence of stone, which 
is most unusual, to cystitis, or to a congenitally small bladder. 

Diagnosis. — Frequent urination due to transient congestion at 
the neck of the bladder may be confused with cystitis. Such cases, 
however, are of very temporary duration, and respond readily to treat- 
ment, while the urine examination fails to show evidence of bladder 
infection. Pyelocystitis or pyelitis may be confused with simple 
cystitis. In cystitis without involvement of the kidneys the fever, 
which may signalize an infection of the pelvis of the kidney, is lacking. 
It is almost impossible to say positively when the pelvis becomes in- 
volved and when a cystitis becomes a cystopyelitis, for a cystopyelitis 
may exist for weeks without an elevation of the temperature. In all 
cases of involvement of the pelvis, however, there probably was a pre- 
ceding cystitis. Temperature, when present, is a determining factor 
in establishing the diagnosis of pyelitis; further, when there is pyelitis, 
epithelium from the pelvis of the kidney is in evidence in the urine. 

Treatment. — The treatment consists largely in the use of internal 
medication. Most cases respond promptly. Now and then a chronic 
case is seen which proves most obstinate. A case of this nature was 
observed at the out-patient service at the Babies' Hospital. The 
patient, a girl, came with a cystitis well established. Large quantities 
of pus were present in every specimen of the urine examined. In this 
case six months' treatment with bladder-washings and medication was 
required before the patient could be considered improved. She then 
developed poliomyelitis and passed from observation. 

Irrigation of the bladder may be attempted. It has been of very 
little service in my hands. Bladder-washing is carried on with no little 
difficulty and annoyance, and usually with unsatisfactory results. My 
best results have been in the use of urotropin and sodium benzoate, 4 
to 6 grains of each, 3 times daily. The frequent urination is relieved, 
and the successive examinations of the urine show a gradual disappear- 
ance of the pus. 

VESICAL CALCULUS (STONE IN THE BLADDER) 

Stone in the bladder is rarely seen in children under ten years of age. 
Four cases only have come under my observation. The patients were 
boys aged respectively three, four and one-half, five, and seven years. 
In each case there was cystitis, with frequent and sometimes impeded 
and painful urination. 

The management is entirely surgical. 

EXSTROPHY OF THE BLADDER 

Exstrophy or eversion of the bladder is a rare deformity, affecting, 
in most instances, the male sex. This condition is due to a defect in 
the anterior wall of the bladder and to failure of development in the 
abdominal wall. Through the existing hiatus the posterior portion of 



BALANITIS 459 

the bladder protrudes as a mass covered by reddish mucous membranej 
on the surface of which the urine from the ureteral orifices is discharged = 
Other malformations usually exist, of which the most important are 
non-union of the pubic bones, absence of the penis or epispadias, c^b- 
sence or non-descent of the testis, and hernia. In the female the em- 
bryonic cloaca representing bladder, vagina, and rectum may persist. 
A determination of the sex of the patient is occasionally difficult. 

The condition is most pitiable. The constantly discharging urine 
makes cleanliness impossible, and the odor of decomposing urine is 
always present. No means have been devised for a satisfactory collec- 
tion of the urine. My own cases have all been seen in hospitals. In 
these instances abundant cotton in a large pad was bound on the parts 
and frequently changed. The skin surface round the exstrophy should 
be protected with U.S. P. zinc ointment, to which 10 per cent, of white 
wax is added and applied on linen. This makes a fairly satisfactory 
water-proof dressing and prevents the distressing excoriation of the 
skin. 

Operation. — The operation for deflecting the ureters to the sigmoid 
or rectum, while rarely successful, should be attempted. 

After the ureters are successfully placed, there is always the danger 
of a pyeHtis. Cases are recorded, however, in which the results of the 
operation have been most satisfactory. I know of one such instance. 
In this case the readiness with which the rectum assumed the bladder 
function was as surprising as it was gratif}dng to the patient. The 
rectum holds the urine from three to six hours without inconvenience. 

Various plastic operations have been advised, the object being to 
secure a bladder orifice to which some portable urinal may be applied. 

The Male Genitals 

Practically every male child is born with an adherent prepuce and 
with more or less constriction at the preputial outlet. The penis is to 
be considered normal only when the foreskin can easily be retracted, 
laying bare the glans. 

The adhesions and constrictions may be relieved by moderately 
stretching the foreskin and breaking up the adhesions with a fine blunt 
probe, after which the glans should be cleansed, oiled, and the foreskin 
drawn forward over it. The cleansing of the parts with Castile soap 
and warm water, which necessitates a retraction of the foreskin, should 
be practised at least every second day on the uncircumcised. This not 
only keeps the parts clean, but prevents the later formation of adhe- 
sions and a possible phimosis. 

Circumcision should be performed upon every male child. The 
operation does away for all time with the necessity of manipulation of 
the parts. (See p. 461.) 

BALANITIS 

Balanitis is a swelUng and inflammation of the foreskin due to a local 
infection. Unskilled manipulation in stretching the prepuce readily 



460 THE PRACTICE OF PEDIATRICS 

produces a laceration, opening up a means of entrance for bacteria. 
In severe cases the parts first show congestion and then edema. I 
have seen patients with long foreskins which were twisted and swollen 
to a size three or four times that of the penis. In advanced cases there 
will be suppuration beneath the foreskin, with a purulent discharge 
from the orifice. 

Treatment. — If the case is seen early, wrapping the parts in gauze 
or old linen, which is saturated with an ice-cold solution of bichlorid of 
mercury 1 : 10,000 and changed every half-hour, will usually be effec- 
tive. If there is much edema, puncturing in several places, after dis- 
infection, should precede the, wet dressing. If there is a purulent dis- 
charge, the sac should be gently syringed at least twice daily with a 3 
per cent, solution of hydrogen peroxid, diluted one-half with water. 

When the suppuration has ceased, with a return to normal of the 
parts involved, circumcision should be done. Operation during the 
acute stage, particularly with suppuration present, should be avoided 
unless the condition is very urgent. 

PHIMOSIS 

Phimosis consists of a constriction or narrowing of the preputial 
orifice, sometimes to a pin-point. In cases where the foreskin is tightly 
bound to the glands by adhesions the urine may be emitted in drops; 
in other cases the prepuce " balloons out '^ during urination and the urine 
dribbles away. The opening may be sufficiently large to show under 
pressure the margin of the urethral opening, in which instance urination 
will be but little interfered with. 

Phimosis may be productive of various nervous manifestations, 
such as restlessness and irritability. It may be a cause of retention of 
the urine. In two of my cases convulsions were apparently caused by 
phimosis. Both children had repeated convulsions until they were 
circumcised. Both suffered from marked phimosis, with retention of 
smegma and irritation of the prepuce. 

Treatment. — The cases in which urination is impeded require 
prompt relief. This can be furnished temporarily by introducing a 
small probe or a director and carefully slitting the skin with sharp- 
pointed scissors until the glans is reached. The child should be care- 
fully held by an attendant during the operation and great care should 
be exercised in introducing the director. After the operation a wet 
dressing of bichlorid of mercury 1 : 10,000 or a saturated solution of 
boric acid should be applied to the wound until it is healed. 

Circumcision should never be long delayed in cases of phimosis, as 
it furnishes the only satisfactory means of relief. Stretching is very 
apt to be followed by recontraction, which only intensifies the original 
condition, while the unavoidable laceration of the mucous membrane 
may open a favorable field for infection. In hospital and out-patient 
work examples are numerous of the harm resulting from force and lack 
of cleanliness in the management of this simple and easily remedied 
condition. 



CIRCUMCISION 461 



PARAPHIMOSIS 



Paraphimosis is produced by the retraction of a tight foreskin, 
which later becomes so contracted behind the corona as to prevent the 
return venous flow. As a result, the glans becomes greatly swollen, 
deeply congested, and edematous. Urination is impossible. The 
cases which I have seen have all been produced by the mother or nurse 
in an attempt to retract a tight foreskin according to the doctor's direc- 
tions, after he had stretched the prepuce for phimosis. 

Treatment. — If the retracted skin is edematous, it may be punc- 
tured in various places to let out the fluid. Reduction may then be 
attempted by taking the glans between the thumb and the first and 
second fingers of the right hand and making gradual pressure backward 
against the thumb and first finger of the left hand, which grasps the 
penis behind the prepuce. If the reduction cannot be effected in this 
way, as occasionalh^ happens if the case is of long standing or the con- 
traction very tight, a longitudinal dorsal incision may be made in the 
skin at the site of the constriction. After the reduction a wet dress- 
ing of a saturated solution of boric acid or of bichlorid of mercury 
1 : 10,000 should be kept constantly applied to the parts until the 
swelling has subsided. Then circumcision should be done. 

CIRCUMCISION 

Should circumcision be practised as a routine measure? There is 
not the shghtest doubt that it would be for the best interest of every 
male infant if he were circumcised. The operation during the second 
week of life is a trivial matter. In one out of every five male infants 
circumcision is a necessity both for comfort and health. In marked 
degrees of phimosis and balanitis circumcision is the only means of 
rehef. 

An important reason, to my mind, for the operation as a routine 
measure, is that it settles at once and for all time the toilet of the parts. 
The penis after a proper circumcision requires no further manipulation 
on the part of the nurse. The daily retraction of the foreskin and bath- 
ing of the parts is one of the best means of teaching the child self -abuse. 
When the parts are not attended to every day or at least every second 
day, trouble is sure to follow sooner or later, in the form of adhesions 
and inflammation of the prepuce. The sensations produced by the 
retraction and the washing are not unpleasant and the child soon learns 
to produce them himself, through leg rubbing, hand pressure, or other 
means. (See ^Masturbation, p. 479.) Time and again, after having 
stretched the foreskin and broken up the adhesions because operations 
were refused, I have had the case return in a few weeks with the adhe- 
sions and the contractions as bad as before, the nurse or mother, timid 
or neglectful, having failed to follow my directions. In case of phimo- 
sis it may require considerable skill to draw the foreskin forward after 
a retraction. It is not always safe to permit the attendants to attempt 



462 THE PRACTICE OF PEDIATRICS 

it. Not a few times I have seen a paraphimosis (p. 461) which resulted 
from an inabihty to bring forward a retracted tight foreskin. 

The dorsal slit, so often practised as a substitute for circumcision, 
is to be used only as a temporary expedient, and as such may be em- 
ployed whenever circumcision is refused. Never, by any means, does 
it take the place of circumcision, but invariably leaves a long, redun- 
dant flap of skin, which easily becomes irritated, causing no little dis- 
comfort. For the child, it also is a great temptation to manipulation. 

UNDESCENDED TESTICLE 

During the latter part of fetal life the testicles rest in the scrotum. 
In a considerable number of infants, however, one or both testicles 
remain in the canal for varying periods, the descent usually taking 
place during the first year. When such descent does not occur, the 
condition may be considered abnormal. 

In small children usually no inconvenience is caused by the malpo- 
sition of the organ. I have repeatedly found one or both testicles in the 
canal in children up to the sixth year. The testicles may be brought 
down, but disappear as soon as traction is removed. In older boys, 
after the sixth year, the condition may cause trouble because of the 
exposed situation, which subjects the organs to possible injury in play. 
Further, if they are left in the abnormal position, the question of pos- 
sible faulty development is to be considered. 

It is important not to confuse this condition with inguinal hernia, 
hydrocele, or enlarged inguinal glands. On several occasions I have 
known a truss to be applied to an undescended testicle. 

Treatment. — While I have known boys to arrive at the age of ten 
years before the permanent descent occurred, I do not believe waiting 
to be a wise routine procedure. If the testicle is freely movable and 
can be brought into the scrotum, it is safer to wait. Nature will cure 
the condition. When the testicle is fixed and cannot be brought into 
the scrotum, I favor early operation — at least, not later than the sixth 
year. In these cases there is a shortening of the cord, with adhesions, 
which prevents the descent. 

ORCHITIS 

Orchitis is a most unusual disease in the young. I have seen but 
two cases, both complicating mumps. The disease may also be due to 
gonorrhea and to trauma. Tuberculous orchitis and specific orchitis 
occasionally occur, but are exceedingly rare. The disease may be ac- 
companied by hydrocele. When epididymitis is present, it may usu-^ 
ally be traced to an injury or to an existing specific urethritis. 

Pathology. — The inflammation in the epididymis is essentially 
catarrhal, but may involve the interstitial tissue and extend to the 
testis. In the latter organ interstitial changes ordinarily predominate. 

Symptoms. — The process is seldom attended by suppuration, 
though the inflammation may be so severe as to cause fever and other 



HYDROCELE 



463 



mild constitutional symptoms. Local manifestations are pain, swelling, 
increased heat, slight redness, and occasionally some edema of the 
scrotum. 

Treatment. — The management necessitates rest in bed, the use of 
saline laxatives, if necessary, and support of the inflamed testicles by a 
wide strip of adhesive plaster extending from thigh to thigh. The 
application of warm sedative lotions gives much relief from the pain 
and discomfort, and appears to shorten the duration of the attack. 
Lead and opium solution, U. S. P., applied on several layers of gauze 
and covered with cotton- wool, should be renewed every three hours. 
After the acute symptoms have subsided a suspensory bandage should 
be worn for several months. 

HYDROCELE 

Hydrocele is an excessive accumulation of serum in the peritoneal 
process enveloping the testicle and epididymis. In children the con- 
dition is usually congenital, although it may be unapparent at the time 
of birth. Hydrocele is also sometimes caused by direct injury. 



v^ 





Nr^ 




Fig. 58. — Varieties of hydrocele: a, Congenital; 5, infantile; c, funicular; d, encysted; 
e, vaginal (Da Costa's Modern Surgery). 



The affection is commonly described under a classification of the 
following forms: 

(a) Congenital Hydrocele. — This exists when the funicular process 
remains patent, and is frequently accompanied by hernia. The tumor 
is translucent, elongated, oval, and fluctuating, and is reducible under 
pressure without special manipulation. When uncomplicated, this 
swelling, in distinction from one produced by hernia, affords only a dull 
percussion-note and fails to emit a gurgling sound on reduction. 

(6) Infantile Hydrocele. — This type is distinguished from the fore- 
going by the fact that the funicular process in the upper portion of the 
canal is closed. The fluid mass is elongated and irreducible. 

(c) Hydrocele of the Cord (Funicular Hydrocele) . — Simple hydrocele 
of the cord is occasioned by the closure of the canal in its lower portion, 
while the funicular process above remains open. Such a condition is 
not usual. The hydrocele is separate from the scrotum and may be 
associated with a hernia. 



464 THE PRACTICE OF PEDIATRICS 

More frequently the canal is closed at both its upper and lower 
portions, while the intervening part remains open and is distended by 
an accumulation of fluid. 

(d) Encysted hydrocele of the cord is small, translucent, elastic, and 
irreducible, and may resemble an enlarged lymph-gland or an unde- 
scended testicle. 

(e) Hydrocele of the Tunica Vaginalis, with Normal Obliteration of 
the Funicular Process. — ^''Common vaginal hydrocele" is firm, tense, 
fluctuating, and irreducible. Above the upper limit of the swelling the 
cord may be distinctly felt. 

Treatment. — The cure of hydrocele in infants is usually spontane- 
ous. When the hydrocele is exceedingly large, aspiration of the fluid 
under rigid aseptic precautions may produce a permanent good result. 
In cases of the congenital variety, especially those associated with 
hernia, the wearing of a truss is important as a means of assisting in the 
obliteration of the funicular process. Injections of irritants have not 
been necessary in my cases. Such a procedure is rarely to be advised. 
I have seen much harm done by punctures and injections into the sac. 
Several severe cases of infection of the parts have resulted from such 
procedures. 

GONORRHEA IN THE MALE 

Specific urethritis in male infants and male runabout children is of 
rare occurrence. Eight patients under four years of age have come 
under my observation. The oldest of the group, aged four years, 
developed a stricture. The boy's home was in a tenement, and he had 
been repeatedly exposed through another member of the family, who 
hoped to rid herself of the trouble by giving it to the boy. The other 
cases occurred in a children's institution, in which there was an epi- 
demic of specific vaginitis. 

Treatment. — The younger boys appear to respond unusually well 
to an irrigation of 8 ounces of a 1:10,000 permanganate of potash 
solution used twice daily. 

EPISPADIAS AND HYPOSPADIAS 

Both of these abnormalities are congenital defects in the develop- 
ment of the penis, characterized by imperfect closure of the urethral 
groove. 

In most cases of hypospadias the urethra terminates before reach- 
ing the base of the glans. In epispadias, which is much less common 
and frequently accompanies exstrophy of the bladder, the urethra opens 
upon the dorsum of the penis. 

The simpler forms of hypospadias may not require treatment, par- 
ticularly if the urethral opening is within one inch of the normal posi- 
tion of the meatus (Wyeth). When, however, the malformations 
present imperative demands, plastic surgery should be attempted. 



VULVOVAGINITIS (sIMPLE) 465 

The Female Genitals 
vulvovaginitis (simple) 

In simple vulvovaginitis there is an inflammation of the mucous 
membrane of the external genitals, with a slight involvement of the 
vagina in its lower portion. Further extension of a non-gonorrheal 
infection to the uterus and tubes probably never occurs. 

The orifice of the urethra is usually reddened and inflamed. 

Etiology. — Ill-conditioned children, and those improperly cared for, 
furnish the majority of the cases. Now and then an apparently 
healthy girl will develop the disease. 

Irritation from hand manipulation in masturbation, scratching in 
eczema, thread-worms, and constipation may all bring about the dis- 
charge. The ailment is particularly common in anemic girls whose 
vitality is habitually below normal. 

Symptoms. — There is moderate itching and burning of the parts 
and a secretion of rather viscid mucus. In some cases there is a j^ellow, 
purulent discharge, resembling that of gonorrheal infection. The at- 
tention may be first called to the condition because of a staining of the 
clothing. 

Diagnosis. — The condition in which there is a purulent discharge 
requires to be differentiated from gonorrheal vaginitis. This is very 
readily done through bacteriologic examination. Without the aid of 
the microscope differentiation is impossible. 

Prognosis. — The prognosis is favorable. Most cases recover in a 
few weeks. Resistance to treatment and chronicity point to the 
presence of the gonococcus. 

Treatment. — The management comprises both constitutional and 
local measures. The patient should be given a daily living regime. In 
these cases I direct when the child shall rise in the morning, when she 
must retire, and the amount of rest she must take in the middle of the 
day. In this way the output of energy is curtailed and waste is pre- 
vented. The diet is so arranged as to give the patient the most nutri- 
tion with the least amount of digestive activity. Bitter tonics, cod- 
liver oil, and iron are given when indicated. As much out-of-door life 
as is possible is encouraged. In short, the measures advocated in the 
section on Delicate Children (p. 122) are applicable here. 

Local Measures. — Bathing the genitals twice a day with warm water 
and Castile soap, followed by drying with absorbent cotton, prepares 
the parts for an absorbent dusting-powder, which I have found useful 
in these cases. The powder used is of the following composition: 

I^ Acidi borici gr. xxv 

Pulveris amyli, 

Pulveris zinci oxidi aagss 

The more nearly dry the inflamed surfaces are kept, the more 
prompt will be the rehef . If there is a tendency to a free secretion of 
mucus, the powder may be applied at intervals of two hours. 
30 



466 THE PRACTICE OF PEDIATRICS 

A convenient means of applying the powder is with an insufflator, 
which may be obtained from any apothecary. After the parts are 
packed with the powder, a dressing of old Unen should be applied and 
held in position by a napkin binder. The powder should be reapplied 
often enough to keep the parts dry. 

I have known many cases of long standing to respond promptly to 
the above management. 

GONORRHEAL VULVOVAGINITIS (SPECIFIC VAGINITIS) 

Vaginitis of this type is very prevalent among the congested tene- 
ment population in all large cities. Institutions for children, if they 
would admit the patients, could always supply a goodly number of 
cases. 

Etiology. — It is almost impossible to keep the infection out of in- 
stitutions, and when it once enters, it is most difficult to remove. The 
disease is quite distinct from venereal disease in the adult, in that it is 
contracted through indirect means. The hands of the mother or nurse, 
towels, napkins, the thermometer, may all furnish a means for trans- 
mission from the infected to the healthy. Day nurseries, most neces- 
sary institutions, are often unwittingly distributing agents of the 
gonococcus. 

At the New York Nursery and Child's Hospital I have labored with 
this disease for several years with most discouraging results. For the 
reason that this is a city institution, cases with vaginitis must be ad- 
mitted and the institution is never free from the disease. 

In private work I have known of several cases in which the mother 
had a vaginal discharge of a suspicious character. In two cases only 
the disease was evidently contracted from a nursery maid. 

Age. — No age is exempt. I have treated infants of six weeks with 
the infection. In older girls, after the tenth year, the possibility of 
infection through sexual contact may be considered, but even at this 
age the disease is most unusual; in fact, very few cases are seen in 
children after the eighth year. Very young females — under three 
years of age — furnish most of the cases. 

A resistance to the special forms of transmission of the infection 
appears to be acquired with advancing years. The nursery maids in 
training will live for months in an infected ward, working with the pa- 
tient, and not become infected, whereas if a healthy female infant is 
placed at any point in the room, she will become infected in twelve to 
thirty-six hours; practically none escape. 

A female child six months of age, admitted into a ward maintained 
with care and cleanliness, containing 12 healthy females of about the 
same age, wiU transmit the disease to one-half of the number in two or 
three days. 

Symptoms. — Redness of the vulva may be apparent without dis- 
charge, or there may be a mucous, mucopurulent, or purulent dis- 
charge. 



GONORRHEAL VULVOVAGINITIS (SPECIFIC VAGINITIS) 467 

The typical discharge is thick, viscid, and of a greenish-yellow 
color. If the case is of considerable duration, there will be redness and 
excoriation of both mucous and skin surfaces. There is a good deal of 
itching and discomfort. In older children micturition may be painful. 
In infants no discomfort whatsoever appears to be occasioned by the 
disease. 

Extension of the infection through the uterus to the tubes and pelvic 
cavity is of most unusual occurrence. I have seen hundreds of these 
cases, but never saw a complication of this nature. The inflammation 
very rarely extends beyond the cervix. An endocervicitis, however, is 
usually present. 

Diagnosis. — The presence of a vulvovaginal inflammation with 
or without discharge suggests the possibility of a specific vaginitis. It 
is a mistake to suppose that there must be a visible discharge in each 
case. Time and again smears taken from a vagina that is simply 
moist will show the gonococcus. 

Microscopic examination of the secretion must decide whether or 
not the case is of gonorrheal origin. 

Fhrognosis. — A guarded prognosis must always be given. Under 
the care of a trained nurse and inteUigent mother I have seen cases 
recover in 3 weeks, but usually from 4 to 8 weeks are required and then 
the management suggested below must be followed out most thoroughly. 
Vaginitis among female patients in an institution is much more 
difl&cult to cure. 

Complications. — The most frequent complications are conjunctivitis 
and arthritis. Conjunctivitis is the one most commonly encountered. 
Arthritis (p. 656) is not at all unusual. I have seen at least 30 of these 
cases. 

Prophylaxis. — This disease is the most infectious of all infectious 
diseases. In order to prevent its spread in a family in which there are 
two or more girls, or in an institution, it is necessary not only to prevent 
personal contact, but also to prevent any association of any nature 
whatever, and this includes attendants, clothing, feeding and cooking 
utensils, and thermometers. 

It seems almost impossible for nurses in attendance in vaginitis 
cases not to convey the disease to well female infants. At the New 
York Nursery and Child's Hospital we were obliged to put the children 
in a separate building, with nurses who cared for them only. Cheese- 
cloth napkins were used, which were burned. All other clothing and 
bed-linen was boiled before being taken to the general laundry. 

Treatment. — The course of the disease is most protracted, and there 
is no specific medication which we may use either locally or internally. 
I have treated hundreds of these cases in many different ways, includ- 
ing the use of solutions of bichlorid of mercury and of permanganate of 
potash of different strengths. I have used the various silver salts in 
different strengths as applications to the parts. I have learned, in 
treating a vast number of these cases, that keeping the parts clean 
through douching does more toward terminating the disease than does 



468 THE PRACTICE OF PEDIATRICS 

the use of any particular disinfectant wash or appHcation. Douching 
of the parts is to be practised four times daily, if possible, with the use 
of two quarts of water. It is useless to attempt the treatment of a 
case without provision for douching at least twice a day. It may be 
remarked that this is a very trying treatment for both patient and 
nurse. Such is certainly the case, but we are dealing with a disease in 
which only strenuous measures give hope of cure. In order to receive 
the douche most effectively the child is placed on the back on a douche- 
pan. A glass female catheter attached to a fountain-syringe is all the 
apparatus required. The catheter is passed about one-half inch within 
the vaginal orifice, and the water allowed to run. The lower end of 
the bag should not hang higher than two feet above the child's body. 
Boric acid is a safe drug in any household. For this reason it is selected 
instead of bichlorid of mercury, permanganate of potash, or any other 
antiseptic. I am not at all sure that plain boiled water would not answer 
just as well. It would be difficult, however, to persuade many families 
to use the repeated douching without the addition of some antiseptic 
to the water. Accordingly, the mother or nurse is instructed how to 
prepare two quarts of a saturated solution of boric acid. This is used 
as a cleansing agent. After the parts are dried with sterile absorbent 
cotton, a dusting-powder the formula of which is as follows is used 
very freely: 

I^ Acidi borici gr. xxv 

Pulv. amyli, 

Pulv. zinci oxidi aa§ss 

The powder is freely dusted into the vagina and over the diseased 
surface after the douche, and at two-hour intervals, during the time the 
child is awake, from early morning until late at night. I tell the atten- 
dants to pack the parts with the powder. Over this is placed absorbent 
cotton or gauze, which is covered with the napkin. The attendants 
should be warned of the danger of infecting themselves and other chil- 
dren in the household with towels, sponges, etc. ; in fact, sponges should 
never be used in these cases. The danger of infecting the eyes, not 
only of the patient, but of the attendants and others who may come in 
contact with the case, should be carefully explained. When washing or 
drying is necessary, absorbent cotton or old linen should be used and 
immediately burned. A child suffering from gonorrheal vaginitis 
should sleep alone. Cheese-cloth napkins should be used and burned 
as soon as soiled. 

A case treated as above may recover in three weeks, though usually 
from four to eight weeks are required, and in some cases the treatment 
must be continued for months. After we have arrived at a point where 
we consider the case cured, there will sometimes be a renewal of the 
discharge; the treatment must then be resumed. 

Before the case is finally discharged, at least two bacteriologic ex- 
aminations of the vaginal secretion should be made in order to deter- 
mine positively the absence of the gonococcus. 

What becomes of the many cases in which the treatment is not con- 



ATRESIA OF THE URETHRA AND VAGINA 469 

tinued or the cases that are never treated? I am confident, from the 
large number of infant females who have the disease and its absence in 
older children after the fourth year, that cure takes place spontane- 
ously, without after-results. The gonococci become fewer in number 
and eventually disappear. 

Vaccine Treatment. — Treatment of the disease with the vaccines 
offers no better results — probably not as good results as are obtained 
by local cleanliness and the above treatment. 

The vaccine treatment has been given a thorough trial at the New 
York Nursery and Child's Hospital. This institution is obliged to 
receive any infant sent by the authorities with the result that there 
are always a dozen or more cases of vaginitis in isolation. The use of 
vaccines has been discontinued at this institution. 

ATRESIA OF THE URETHRA AND VAGINA 

Atresia of the Urethra. — This is a congenital occlusion or stricture 
of the urethra, due to agglutination of the walls or closure of the 
meatus urethrse by membrane. The obstruction is often incomplete. 

Treatment. — In some instances simple incision at the meatus may 
relieve the condition. The other cases will require urethrotomy, com- 
bined, perhaps, with forcible catheterization. 

Atresia of the vagina may be due to imperforate hymen (atresia hy- 
menalis) or to the presence of a transverse septum obstructing the 
passage at a higher level. A rectovaginal fistula may coexist with 
the atresia. Atresia of the vagina has been recognized as a cause of 
hematocolpos, hematometra, and hematosalpinx. The possible exist- 
ence of this malformation should be considered in all cases of delayed 
menstruation. 

The treatment is surgical. 



XIIL NERVOUS DISORDERS 

HEADACHE 

A complaint of headache, particulary repeated headache, on the 
part of a child should always be respected. Its occurrence is of greater 
import than in the adult. 

In children of any age headache may be an early symptom of men- 
ingitis, particularly of the tuberculous form, in which the headache 
may exist for days without other signs of illness. In eye-strain head- 
ache is a very prominent symptom, and may be the only evidence that 
an ocular defect exists. In cases of persistent headache that cannot 
otherwise be satisfactorily explained I invariably have the eyes exam- 
ined. Headache is often the earliest sign of acute infectious disease: 
it is a premonitory symptom of scarlet fever, measles, or pneumonia. 
Persistent toxemia from any source may be a cause of headache. 
Such toxemia may occur in nephritis and in malaria. The most usual 
source, however, is the intestinal tract. With persistent toxemia of 
intestinal origin, anemia is generally associated. This condition may 
exist without constipation. Fatigue, as a result of overwork at school, 
or hard play and unusual excitement, may be a cause of headache in 
neurotic children. Late in the school year it is frequently encoun- 
tered in girls. Examination of the urine may show marked indi- 
canuria. Children are imitators of adults, and in a family with the 
headache habit the child may complain when the condition does not 
exist. Such simulation may readily be interpreted. 

Treatment. — The management of headache consists in the discov- 
ery and removal of the cause. An ice-bag or an ice-cloth applied to 
the head affords much relief in the acute febrile cases. Ocular defects 
should have the benefit of rest and suitable glasses prescribed by an 
oculist. Fatigue headaches are best controlled by limiting the amount 
of work and providing long periods of rest. Headaches due to intes- 
tinal toxemia with the usual accompaniment of anemia are often most 
difficult to relieve. In spite of our best efforts, the intestinal digestion 
may remain faulty for a considerable time. A change of residence and 
a radical change in the habits of life are usually the best means of 
effecting a cure. The management of these cases is considered in 
detail under Persistent Intestinal Indigestion (pp. 205, 206). 

PAVOR DIURNUS 

Day-terrors are of occasional occurrence. My cases have all been 
due to intestinal toxemia in children who showed very poor milk capa- 
city. The fright has never been as severe as that occurring at night. 

470 



NIGHT-TERRORS (PAVOR NOCTURNUS) 471 

Illustrative Cases. — A boy, two and one-half years of age, asked his nurse to 
brush the bugs off his lap-robe and clothes. _ When the nurse failed to discover the 
bugs, the boy attempted to brush them off himself. When asked what kind of bugs 
they were, he repeated ''all kinds." 

A case almost identical with the foregoing was that of another boy three years 
of age. 

A girl four years of age would suddenly stop her play and hold conversation 
with imaginary people or objects and maintain that the people were present, and 
describe their appearance and dress. As suddenly she would return to play. At 
these times it was with difficulty that the child could be brought to her normal 
condition of mind. 

In all these cases there was chronic intestinal indigestion, with 
heavily coated tongue and foul breath. The children recovered en- 
tirely upon relief of the intestinal condition. 

Uncontrollable attacks of screaming in young children have been 
attributed to pavor. 

NIGHT -TERRORS (PAVOR NOCTURNUS) 

In night-terrors the child arouses from his sleep, thoroughly 
frightened, imagining that animals or persons are trying to injure him. 
He begs to be protected. The following morning he has no recollection 
of the occurrence, and is rather amused than annoyed at the episode. 

Etiology. — In a great majority of the cases the trouble is due to a 
deranged digestion in a neurotic child. This, however, is not neces- 
sarily the case. I have repeatedly known apparently healthy children 
to have the attacks. In my most recent case the terrors were due to ex- 
cessive fatigue. 

Illustrative Case. — The boy, four years old, had been treated elsewhere and 
had received careful medication and diet. The attacks continued nearly every 
night for a year. The mother stated that her own health and the boy's were badly 
affected because of the broken night's rest, and she looked upon the condition as 
very serious. Upon learning every detail of the boy's life I discovered that 
there was an older and very active brother of six years with whom the patient 
played daily, and who acted as a pacemaker for the patient. The older boy was 
sent from home, and a quiet, uneventful life was prescribed for the younger boy. 
There was no change in diet, as this was not necessary. For one week 8 grains of 
bromid of soda was given at bedtime to break the habit. During the next ten 
days there were two mild attacks. After this the boy slept throughout the night. 
There was no relapse for eighteen months. 

Such cases as the foregoing are unusual. Indulgences in unusual 
articles of diet cause many attacks which may be compared to night- 
mare in the adult. When repeated attacks occur, it will usually be 
found that the child is suffering from persistent intestinal indigestion, 
or that the evening meal is, as a rule, beyond the patient's digestive 
capacity. 

Illustrative Case. — A boy patient who was four years of age when he came under 
my care had, during the next five years, two attacks of night-terrors each year. 
One attack occurred on the night of his birthday and the other on Christmas night. 
At those times, in spite of my repeated warnings and the repeated attacks, he was 
indulged in unsuitable articles of food. 

Overwork at school and anxiety regarding school duties and lessons 
have been factors contributing to night-terrors. Contributing factors 
also are adenoids, enlarged tonsils, and worms. 



472 THE PRACTICE OF PEDIATRICS 

Treatment. — If the patient is a school-child and the case is aggra- 
vated, school should be temporarily discontinued and all exciting play 
and books of an exciting nature forbidden. The heaviest meal should 
be taken at midday. The evening meal should consist of cereals, milk, 
stale bread and butter, and stewed fruits. The child should never be 
allowed to go to bed unless an evacuation of the bowels has taken place 
during the previous twenty-four hours. 

In the very nervous and irritable cases, from 5 to 10 grains of bromid 
of soda may be given at bedtime. This should not be continued longer 
than a week. If the child is delicate, anemic, or suffering from ade- 
noids, enlarged tonsils, or thread-worms, these conditions, any one of 
which may contribute to night-terrors, should receive proper treatment. 

GYROSPASM (SPASMUS NUTANS) 

Gyrospasm is a functional nervous affection usually seen in children 
under one year of age. I have seen but two patients over one year old. 

Etiology. — I have seen a considerable number of these patients, 
and all have been children suffering from malnutrition. Rachitis is 
always present. Two of my patients were mentally defective. 

Symptoms. — The disorder consists of a rhythmic rotatory move- 
ment of the head, at times from 20 to 40 oscillations being made in a 
minute. The movement may not only be lateral, but vertical, which 
constitutes what is known as head-nodding. In one of my patients 
both the lateral and vertical movements took place. 

The oscillations are usually, but not invariably, associated with 
nystagmus. . The movements of the head occur only when the child is 
erect, and the oscillations with the nystagmus are increased when the 
child's attention is focused on some object. 

Prognosis. — The prognosis is good if the child is mentally normal. 
None of these children die of this disease, and practically no cases 
are seen after the eighteenth month. With improvement in the phys- 
ical condition and development of the nervous system, the motions 
cease and occur only under excitement. The disorder is essentially 
chronic, and the improvement is slow. The mother becomes dissatis- 
fied with the treatment, and wanders from clinic to clinic. This ex- 
plains in part the large number of cases seen by pediatrists. 

Treatment. — The only treatment of value is along nutritional 
lines. I have had the opportunity to give a few cases a fair trial with 
sodium bromid in doses from 12 to 18 grains daily, a treatment which is 
generally advocated for this condition, but have failed to note any spe- 
cial benefit from the method. With an increase in age and improvement 
in nutrition the cases which I have been able to follow have slowly 
improved and recovered. 

HYSTERIA 

Hysteria is a functional disorder, rare in young children, and char- 
acterized by nervous crises. My youngest patient was 33-^ years old 



HYSTERIA 473 

when first seen by me, but the hysteric manifestation had been pres- 
ent for several months. Mental, motor, or sensory manifestations 
may predominate in an individual case, although in all cases the condi- 
tion is associated more or less directly with an absence of mental control. 
Girls are more frequently affected than boys, but some of the most 
typical cases coming under my observation have been among the 
latter. 

Etiology. — ^We are taught by neurologists that hysteria is almost 
invariably of hereditary origin because of its apparent direct trans- 
mission from parent to child. It must be remembered that the 
child, in addition to being born of an hysteric mother, is in constant 
association -with her. To my mind, in hysteria we have exempli- 
fied in the most perfect degree the effect of environment. A neurotic, 
hysteric mother puts the whole family in a state of high nervous 
tension. I know of several such instances. A neurotic, irritable father 
will make the whole family neurotic. I know of such instances also. 
Fortunately for the offspring, both conditions are seldom combined in 
one family. When they are (and I have the children of a few such 
families under my care), the future of the children is discouraging. 
When one of the parents is sufficiently normal to offset a reasonable 
degree of neurosis on the part of the other, a stable equilibrium may 
be maintained. 

Imitation is one of the strongest characteristics of the growing child. 
How often, when arranging with the mother a diet-list for one of these 
nervous, ill-conditioned children, have I heard the child say that he 
*' hated" cereals, or ''hated" vegetables, or "hated" eggs or fowl; or 
that he ''adored " some other articles of food; this adoration and hatred, 
particularly the latter, often influencing the entire future of the child; 
for without a properly regulated diet for every day in the year only 
an inferior type of adult can be the outcome. In such cases it will 
usually be found that the likes and dislikes of the child are identical 
with those of the parents, whose preference has often been expressed 
in the presence of the child. "Heredity" here furnishes to the parents 
a satisfactory explanation of the child's limitations in diet. It will 
usually be found that parents who live normally have children who eat 
normally. 

Illnesses and ailments of different kinds should not be discussed 
before nervous and impressionable children. Time and again an in- 
vestigation of a peculiar pain in a child's head, side, or back which 
cannot be accounted for by the physical examination will be explained 
by a similar pain in some older member of the family. 

Illustrative Cases. — In one family I have seen three generations of genuine 
hysteria. In the first generation the father, chronically irritable and neurotic, was 
a business man with large interests, rarely ceasing, when at home, to talk about 
his ailments and their remedies; and the mother had marked hysteria, indulging in 
frequent attacks, with apparent unconsciousness lasting for hours. The daughter, 
brought up in this atmosphere, through heredity and environment soon became 
markedly hysteric. When some dispute arose in the family, which was not an in- 
frequent occurrence, both she and the mother would have simultaneous attacks of 



474 THE PRACTICE OF PEDIATRICS 

hysteria. In due time the daughter married and gave birth to a daughter, who 
promises to maintain the family traditions, with certain additions of her own. 

A girl seven years of age lived in deadly fear of appendicitis and developed an 
attack of hysteria every time she had a pain. She could locate ''McBurney's 
point," and knew the various stages in the development of the disease and the steps 
in the operation for appendicitis. The mother's appendix, suitably preserved, is 
among the family relics, whence it cannot be removed. The influence of heredity 
perhaps had the effect of making the child alert, precocious, and impressionable. 
Such favorable soil and the constant association with the hysteric will almost 
surely develop hysteria in a child. 

Symptoms. — Three forms of hysteria may be seen — the normal, 
motor, and sensory types. An individual may show one, two, or all 
of the types. 

Hysteric patients will be found who have indulged in ''tantrums" 
from very early life. They enjoy their seizures, which are usually 
manifested by laughing and crying violently in alternation; and not 
only do they enjoy the indulgence in an attack, but the attention they 
receive. They are usually obstinate, and do not attempt to exert 
what mental control they may possess. They may become most 
violent. Upon attempting to quiet a strong girl of ten years in a 
violent seizure of hysteric mania I came out a victor, but required the 
use of plaster bandages as well as the service of a tailor before I could 
continue the work of the day. 

Illustrative Case. — The Motor Type. — A girl thirteen years of age had not been 
able to walk for three weeks; she was most calm and collected. Examination 
showed her muscle and nerve condition to be normal. There was no hyperesthesia 
nor anesthesia, and the muscles of the legs and back were entirely under her control 
when she was in bed. As soon as she attempted to walk the legs gave way and 
she sank to the floor. About one year before she had passed through a period when 
the left arm could not be used for three weeks. She was very fond of looking out 
of the window. She soon could walk in the direction of the window, but would 
fail utterly when walking in any other direction. Likewise she could stand by the 
window and in front of the mirror, — she was decidedly handsome, — but in other 
situations the legs would not support the body. 

The convulsive cases exhibit every variety of contortion. The 
patients throw themselves about in apparent unconsciousness, without 
regard, yet it will be remarked that they always manage to fall in a soft 
place. Hysteric patients never injure themselves to any extent. If 
they pull their hair, they do not pull very hard. They pull another 
person's hair much harder than their own. 

Illustrative Case. — A girl of eleven upon little or no provocation would pass into 
a trance-like state and remain in this condition for five or six hours until she became 
very hungry or thirsty. During the attack it was impossible to arouse her by any 
ordinary means. On one occasion I cried "Fire! Fire!" in an adjoining room. 
This promptly brought her to her feet. Later attempts along this line were without 
effect. I instructed that no attention be paid to her when in the attack. The 
attacks then ceased to be interesting to her and terminated. 

Globus hystericus, hiccup, and inability to speak, have all been en- 
countered from time to time. 

Illustrative Case. — A girl of eight developed an incessant cough, which drove 
the members of the family to distraction, but was easily controlled through 
suggestion. 



HYSTERIA 475 

That imitation is a factor of much importance is shown by the 
dancing mania of former days, and more recently by the school epi- 
demics, necessitating the closing of the school. 

Illustrative Case. — In a country school a new girl had habit chorea. Two of the 
larger boys amused themselves imitating her. Other small boys and girls imitated 
the boys, and soon the whole group of 30 children were grimacing to such an extent 
that a temporary closure of the school was necessary. 

Hyperesthesia and anesthesia are not common. 

The Sensory Type, — This manifestation in children is also quite 
unusual. Hysteric anorexia or hysteric vomiting has occurred in a 
few instances. In hysteric anorexia the patient may be unable to eat 
in the presence of a certain person, or exhibit inability to eat in a cer- 
tain room or locality, or be able to eat only with certain utensils or in a 
favorite room or locality, or with the body in a special position. 

Illustrative Case. — A girl three years of age was brought to me for treatment 
because she vomited at the table, over the table, and over any one who was suffi- 
ciently near. Not every meal was lost, and food given between meals was retained. 
There was suffiicient disturbance of nutrition to warrant anxiety on the part of the 
mother. I found the child pale, thin, undersized, and showing a moderate second- 
ary anemia. From infancy there had been some gastro-intestinal disturbance, 
and the child had been the source of much anxiety to the mother in this regard. 
For about a year the vomiting at the table had been very distressing. The child 
had been treated in various ways for stomach disorders or disease, without any 
improvement whatsoever. After a thorough examination and review of the case 
I made the diagnosis of hysteria, and directed that the mother, who had neurotic 
tendencies, should keep apart from the child as much as possible. The child was 
not allowed to dine with the mother, but was permitted to dine in the kitchen with 
the maid of all work. The vomiting stopped at once. After about ten days of 
dining in the kitchen, during which the patient showed marked physical im- 
provement, the maid was called away on account of illness; the child returned to 
the family table, and again promptly vomited once or twice a day at about the 
completion of the meal. In three days the maid returned and the child took up 
dining in the kitchen, with the former satisfactory results. This continued for a 
few weeks; then there was a disagreement between mistress and maid, and the 
maid left, never to return. Again the child was placed at the family table, and 
again the vomiting recurred. Whether the child ate with the family or dined 
alone, the presence of the mother was sufficient to produce the vomiting. Ac- 
cordingly, after many terrible trials and many failures, the mother, thoroughly 
distracted, placed the child in the family of nearby relations, where there were 
other children. Here she retained her food and throve. 

I have treated other vomiting cases of similar nature, but none so 
obstinate. 

Diagnosis., — The diagnosis of hysteria is made chiefly by exclusion 
of sj^mptoms referable to organic disease of any nature. Electric tests 
and other forms of examination will establish the non-pathologic char- 
acter of the illness. 

Duration. — There is a marked tendency to relapse. Patients who 
continue to Hve under the original neuropathic environment usually 
continue to enjoy their hysteria. Duration and prognosis depend 
upon the opportunity for right management and cooperation on the 
part of the family and friends. 

Treatment. — -General. — My results with hysteric children have 
usually been very good or very poor, depending to a great extent upon 



476 THE PRACTICE OF PEDIATRICS 

my ability to separate the child from the family. By this statement 
the proper management of hysteric children is indicated. The child 
should, if possible, be removed from the unfavorable family influence. 
The boarding-school has effectually cured several of my cases. Here 
the child is placed under the care of trained teachers, who bring out the 
good and correct the bad by reason, precept, and example, and thus 
exert a continuous beneficial influence. In the boarding-school, plain 
diet, pleasant occupation, agreeable association, and a scientifically 
regulated life replace the spoiling and coddling, and often the unsuit- 
able food, together with the endless nagging which the neurotic mother 
is very apt to indulge in, with the best intentions, of course, but never- 
theless with a most unfortunate effect upon the child. If the child is 
too young for a boarding-school, or if admission is denied him, he should 
be placed under the care of some kindly, well-balanced woman as 
companion and instructor, and see as little of his family as possible; 
otherwise but little can be expected from the treatment. Of course, 
the conditions must be explained fully to the parents, in order that they 
may make an effort to regulate their bearing toward the child in the 
right direction. If the former intimate associations with the child 
continue, the good intentions, according to my observation, may prove 
effective only a very few days. It is impossible to reform the habits 
of life of a neurotic adult. Once hysteric always hysteric does not 
come far from the truth. If an individual has grown that way, that 
way he will remain. The only hope for the child is in his complete 
removal from such unfavorable influences. 

Physical and Mental Activity. — The further treatment of hysteric 
children consists in curtailing the mental and physical activities, which 
almost invariably have been excessive. A rational scheme of living 
should be formulated. "Showing off" the child to visitors and others 
should be forbidden. If the patient is under ten years of age, he should 
retire at 7 o'clock every night, and rise at 7 every morning. It is to be 
understood by the attendant that this does not mean 6.45 or 7.15. 
Every day after the midday feeding the child should rest quietly in a 
darkened room for an hour or two. Whether he sleeps or not, he 
should rest in a recumbent position with clothing removed. For such 
children exciting games of stress and competition of every nature are 
forbidden. An outdoor life is to be encouraged. A bicycle, a pony, an 
individual play-room in winter, and a tent on the lawn in summer, 
should be provided when possible. School instruction may be given, 
but the child is not to be crowded. The amount of study and school 
work depends, of course, upon the child's condition. Until the tenth 
year, however, there should be but one session (and that in the morn- 
ing) of one and one-half to three hours. The child should be given a 
tub-bath or brine bath daily at 90°F. (p. 780). At the completion of 
the bath he should stand with his feet in warm water and be given a 
cool douche at 70° to 60°F., the spray tube being attached to a faucet. 
Cold water may be poured down the spine. This application of cold 
water should be for a few seconds only and should be followed by 



HABITS 477 

brisk rubbing with a rough towel, which should result in a decided skin 
reaction. 

Treatment During Hysteric Seizure. — During a hysteric seizure the 
child should be treated with kindness, but with firmness. No sympa- 
thy should be shown. The application of ice-water to the face and 
chest is usually sufficient to break up an attack. In some cases a cer- 
tain amount of time appears to be required for a return to the normal. 

Drugs. — Sedative drugs, such as the bromids, should not be used. 
Cases have come under my observation showing the bromid rash. 
Such treatment, as also the use of the opium derivatives, cannot be too 
strongly condemned. Drugs that increase the appetite and improve 
nutrition should be given. I have found that iron and arsenic answer 
well in these cases, as most of the patients show a secondary anemia. 
For a child from five to ten years of age the following prescription has 
been useful: 

I^ Liquoris potassii arsenitis .gtt. xc 

Extracti ferri pomati gr. x 

Quininae bisulphatis gr. Ix 

M. div. et ft. capsulse no. xxx. 

Sig. — Take one after each meal. 

If constipation results from the use of the small doses of iron, 3^ to 
J^ grain of the extract of cascara may be added to each capsule. If the 
child cannot swallow a capsule, the following may be used : 

I^ Liquoris potassi arsenitis gtt. Ixxii 

Ferri et ammoniae citratis gr, xxiv 

Elix. simplicis gss 

Aquae q. s. ad 5iv 

M. Sig. — One teaspoonful after each meal in a glass of water. 

The iron and arsenic may advantageously be alternated with pure 
cod-liver oil, — one to two drams after meals, — each medicine in turn 
being given for seven successive days. Alcohol should form no part 
of the medication of these children. In using the so-called liquid pro- 
prietary foods, it is to be remembered that some contain a consider- 
able percentage of alcohol. 

HABITS 

Children readily acquire habits, good or bad. Under the manage- 
ment of an intelligent attendant, directed by the physician, natural 
tendencies toward the repetition of an act may be turned to the child's 
inestimable advantage. In earliest infancy the habit of taking the 
nourishment at definite periods should be established, and as the child 
increases in age, proper habits of sleep and rest must also be acquired. 
The child should be bathed at a stated time and aired at a stated time 
each day, and, in general, in order to fulfil the requirements of vigorous 
animal life, his Hfe should conform to a routine in which there is but 
little variation. As our sole object is the production of a normal adult, 
only those habits tending toward proper growth and development 
should be encouraged. The habit of self-entertainment is important. 



478 THE PRACTICE OF PEDIATRICS 

An infant who requires to be constantly in arms when awake will have 
a tired attendant, and usually will develop into a tired and irritable 
child. 

Bad Habits and Their Correction. — Among the bad habits early 
acquired and difficult to break are those of thumh-sucking or finger-sucking 
and the use of the ^^ pacifier.'' The penalty paid by these children for 
such indulgence is thickened, boggy lips, due to hypertrophy of the 
orbicularis oris muscle and adjacent structures. Persistent sucking 
also produces a forward projection of the upper incisor teeth and an 
angular deformity of the upper jaw. The correction of the rubber- 
nipple and pacifier habit is readily accomplished by the immediate 
withdrawal of these articles. The child will experience several fretful 
days and make association temporarily unpleasant for those about him. 
The thumb-sucking habit may be corrected by having the child wear 
a mitten or glove made of muslin or old linen which is shirred and tied 
at the wrists. The Hand-I-Hold Mit (Fig. 61) answers the purpose of 
preventing thumb- and finger-sucking better than any other article. 
The child has full use of his arms, yet the hands contained in the alumi- 
num mit are free from manipulation. Applying bitter drugs to the 
fingers or thumb may be effective in controlling the habit. The tinc- 
ture of aloes or a solution of bisulphate of quinin, one dram to two 
ounces of water, is generally used. The fingers should be repeatedly 
moistened with the solution. Mothers will sometimes tell us with con- 
siderable amusement that the application of the bitter drug to the 
finger makes no difference to the child; he appears to like the taste of 
quinin or aloes. The child, however, soon tires of the bitter taste, and 
continued use of the remedy will always stop the habit. Biting the 
finger-nails may likewise be remedied by the use of these bitter 
solutions. 

Picking or rubbing the finger-tips with the fingers of the opposite 
hand is rather an unusual habit. It may cause considerable hyper- 
trophy of the ends of the fingers, so that they will acquire an appear- 
ance not unlike that occasioned in cardiac disease. Mechanical 
restraint is our best preventive. The constant use of gloves or the 
application of strips of adhesive plaster will break the habit. 

Head-banging is, fortunately, an unusual habit. It consists in 
repeatedly elevating and bringing the head forcibly down on the mat- 
tress when asleep. This I have seen done in one instance with sufficient 
force to produce vibrations in the other rooms of the house and inter- 
fere with the repose of the occupants. Every means and device for 
preventing the banging was tried without effect. Finally the patient 
became such a nuisance to his family that he was made to sleep in a 
hammock. This, to the best of my knowledge, was the means of cur- 
ing the condition. 

It is surprising in how many ways children develop habits of 
manipulating different parts of the body. 

Head-rolling. — Head-roUing is practised with the child resting on 
its back; the head is rolled rapidly from side to side. A two-year old 



MASTURBATION 479 

child at the Nursery and Child's Hospital immediately began this rolling 
whenever it was rested on its back. As many as 50 oscillations would 
be made in a minute. In this position the child continued until over- 
come by fatigue or sleep. We were unable to control this habit and 
the child passed out of the hospital with the rolhng in full force. 

Illustrative Cases. — One of my most troublesome cases was that of a child one 
year old who came to me with an ear stretched to twice its normal size. During 
the greater part of the waking hours the child grasped and pulled at the top of the 
left ear. 

Another patient was brought because of the habit of burrowing the right thumb 
into the right nostril. The nostril had become stretched to at least three times its 
normal size, causing a most peculiar deformity. 

An eight-year-old girl developed the habit of striking her left leg at the calf 
with the heel of her right shoe when walking. Her stockings soon became worn 
and soiled, and the child presented a ridiculous appearance in public. In running 
or in going up and down stairs the habit was not practised. The girl was brought 
to me because of the peculiar habit, which had been kept up for several months. 
She had received the usual punishments and rewards without effect. Upon 
discovering that she only practised the leg-banging when walking, I advised a 
treatment which proved effective. This consisted in not allowing the child to 
walk for six months. She was made to run or walk rapidly, whenever walking 
was necessary. 

A girl six years old, without eczema or any evidence of irritation, cam_e to me 
because of the habit of rubbing the right thigh. While walking a city block she 
would raise the clothing with the right hand and rub the outer lower third of the 
thigh for a second. This act, according to the mother, would be repeated a hun- 
dred times a day if there was no interference. The treatment suggested in this 
case was simple and effective. Several thicknesses of a roller bandage were used 
in covering up the favorite skin area. Whatever gratification was experienced by 
the manipulation was thus done away with, and the habit was promptly broken. 
The parts were kept bandaged for three months. 

The most pernicious habit, that of masturbation, is referred to 
below. 

It is impossible to make more than general suggestions for the 
correction of bad habits in children. When there is manipulation of 
the mouth, the sense of taste can usually be made to aid us. In other 
instances restrictions of a mechanical nature may be necessary. In the 
ear-pulling case, a tight-fitting muslin cap was worn constantly and the 
right hand kept pinned to the clothing. Punishment, rewards, and 
ridicule all may be emploj^ed in the treatment of these cases. As a 
rule, however, such measures are not as effective as mechanical 
restraint. Bad habits as to hours for feeding and sleeping, as well as 
the habit of carrying a child in arms — all may be corrected by doing the 
right thing at the right time and having a sufficient amount of courage 
to persist. It is to be remembered that, regardless of age, a child is 
never harmed by rigid discipline properly applied. 

MASTURBATION 

Before the fifth year a great many more cases of masturbation 
are seen among girls than among boys. After that age it is more 
frequent in boys. The most common means of practising masturba- 
tion in either sex in infancy is by leg-rubbing. Contact by means of 
the edge of a chair or the corner of a sofa or any object against which 
pressure may be exerted is not infrequently the means used by older 



480 



THE PRACTICE OF PEDIATRICS 



girls. Manipulation of the parts, while only occasionally seen in girls, 
is the usual method of boys after the third year. My youngest 
patient was a female child six months of age who was a * 'leg-rubber," 
and who evidently passed through a complete orgasm. In many the 
habit will be indulged in several times a day. 

In boys the primary causes of the practice are an elongated foreskin, 
adherent prepuce, and phimosis. The handling of the parts necessary 
to keep the uncircumcised clean is an exciting factor. In girls, vulvitis 
and vaginitis, and adhesions of the clitoris with the retained smegma 
and resulting irritation, are frequent causes. It is a popular notion 
that thread-worms may be an exciting factor, but among many cases 
of masturbation and many cases of thread-worms I have never seen 
both conditions in the same child. 

Prophylaxis. — Masturbation is much easier to prevent than cure. 
In boys, prevention lies in keeping a clean, free glans, which in the 
great majority of male infants can be obtained only after proper sur- 
gical procedures. The elongated, thickened, uncut portion of the 
foreskin usually seen below the glans after a ritual circumcision is but 
little better than a free, elongated prepuce. Slitting of the foreskin 
on the dorsum gives a condition very similar in character to that of a 





Fig. 59. — Knee-crutch.* 



long, redundant foreskin. In girls, prevention to a certain degree con- 
sists in keeping the parts clean through washing them once a day with 
great gentleness, and the free use of non-irritating absorbent powders. 
A powder composed of equal parts of powdered starch and oxid of zinc 
gives very satisfactory results. 

Treatment. — When the habit of masturbation has been once estab- 
lished, the first step is to eliminate the cause, if it can be discovered, 
and put the parts in a normal condition. Circumcision in boys, and 
releasing the adhesions of the clitoris in girls, with the maintenance 
of cleanliness and as little manipulation as possible, are absolutely 
essential. 

The urine should be examined, and if found highly acid, should be 
corrected by diet and by the use of bicarbonate of soda, six to twelve 
* Made for the author by George Ermold Co., 201 East 23d St., New York City. 



MASTURBATION 



481 



grains being given daily, according to the age of the patient. If red 
meat has formed a considerable part of the diet, the quantity should be 
reduced and given not oftener than three times a week. 

Having removed all possible sources of local irritation, we are in a 
position to use restrictive measures, as it is through such treatment 
only that a cure will finally be effected. If the practice is prevented 
the habit will soon be forgotten. The older the child, the more difficult 
will be the cure. The restrictive measures employed depend to a 
considerable extent upon the age, sex, and method of practice. In 




Fig. 60. — Brace used to prevent manual masturbation.* 

the case of young children of both sexes who practise leg-rubbing, a 
large napkin of some coarse material, or a towel, should be placed over 
the napkin usually worn, and applied in the same way, so as to keep the 
legs widely separated. After the napkin age a large towel may be 
used, if necessary, for the same purpose, or the knee-crutch (Fig. 59) 
may be employed. Some children will indulge only when in a certain 
chair or in a certain position. 

Illustrative Cases. — A very troublesome case in a girl seventeen months old was 
treated without success for several weeks, when I discovered that the child prac- 
tised the act only when in her high chair, as by leaning forward and grasping the 
projecting arms she managed to bring the necessary pressure to bear upon the 
genitals. The use of the chair was discontinued, and there was no further trouble. 

Another girl six years of age was an inveterate masturbator. She had been 

* Made for the author by George Ermold Co., 201 East 23d St., New York City. 
31 



482 



THE PRACTICE OF PEDIATRICS 




r 



treated by several physicians. The act was repeated daily, sometimes two or 
three times a day, usually by contact, such as by pressure against the corner of a 
table, sofa, or chair. When in bed, she indulged in the practice by manipulation. 
She had become pale, thin, and hysterical, and as she was a member of a prominent 
family, great concern was felt for her. The external genitals were congested and 
swollen as a result of the direct irritation, otherwise they were normal. It seemed 
that here was a case where eternal vigilance was the price of safety. The gravity 
of the condition was apparent, and the parents readily agreed to my suggestion 
that the child should never be left alone. The mother and the nursery maid took 
turns in being with the child in the daytime. A trusty middle-aged woman was 
selected for the night watch. I directed that no reference be made to the habit, 
but that the child should be severely punished if the practice was attempted, 

This, however, was not needed. This child, as 
is the case with all older children, masturbated 
in secret, and as she was never left alone, 
stopped the practice. She was given suitable 
food, teaching by a visiting governess was be- 
gun, ^ and hard play was soon advised, as her 
physical improvement was rapid. As there was 
no further tendency to masturbate, the night 
watch was withheld after six months. The 
child was kept under the closest observation, 
however, for a much longer time. Cooperation 
to such a degree as in this family may, how- 
ever, rarely be secured. 

Older children who practise manipu- 
lation of the parts can usually be watched 
during the daytime, but the habit is fre- 
quently indulged in on going to bed, af- 
ter the lights are out, and in the early 
morning, particularly when prevented 
during the day. In such instances I 
have been obliged to advise mechanical 
restraint. An inexpensive and effective 
means is a piece of tape, which is tied in 
the center around the child's neck in a 
flat knot, leaving the two ends long 
enough to be securely tied around the 
wrists, so as to allow a free movement 
of the hands above the umbilicus. The 
child can use the handkerchief, and ad- 
just the bed-clothing, but cannot touch 
the genitals. If the patient is a girl and a masturbator by contact 
with any object, or a leg-rubber, a large bath-towel, if worn like an in- 
fant's napkin, will aid materially in discouraging the practice. A 
brace (Fig. 60), constructed of steel, with a hinge-joint to allow the 
arm to be extended to an angle of about 45 degrees, has been used 
with success in a few cases. This brace is worn only at night.* 

The "Hand-I-Hold Mitt."t — As a means for the prevention of 
scratching, thumb- and finger-sucking, nose-boring, ear-and lip-pulhng, 
and masturbation the "Hand-I-Hold Mit" renders good service. The 
child has free use of the arms and the fingers are movable inside the 




c 



Fig. 61.— The Hand-I-Hold 
Babe Mit and method of ap- 
plying : a, First, roll sleeve over 
ball to expose opening, then in- 
sert the child's hand; h, second, 
tie tape at wrist and pin with 
safety-pin to dress at elbow. If 
mit is not held in place firmly 
enough, use a broad piece of 
cheese-cloth in place of tape. 
Bind this firmly around the 
wrist and tie; c, a;-ray view 
showing freedom of hand. 



* This device had its origin with Dr. Gerald Webb of Colorado Springs. 

t Manufactured by R. M. Clark and Co., 246 Summer Street, Boston, Mass. 



INFANTILE CONVULSIONS 483 

mit. In eczema, however, it may serve as a very attractive means 
of rubbing the diseased surfaces. 

HICCUP 

Hiccup is a spasm of the diaphragm, usually due to gastric irrita- 
tion from the distention of the stomach or intestine with gas, or over- 
loading of the stomach with food. Under such conditions the spasm 
is usually of little consequence, and may readily be relieved, if the 
attack is prolonged, by an enema of soap-water and a laxative dose of 
rhubarb and soda. With any grave illness, however, it is a symptom 
of serious import. Hysteric girls often have hiccup to quite an alarm- 
ing degree. The attack usually follows a period of unusual excitement. 
In these cases from 20 to 30 grains of bromid of soda repeated in from 
twenty to thirty minutes will usually control the spasm. 

INFANTILE CONVULSIONS 

A convulsion consists of a temporary loss of consciousness, associ- 
ated with rhythmic clonic contractions of various muscles of the body. 
We are deahng with a symptom, and not with a disease. 

During the early days of life a convulsion is always of serious im- 
port, as it frequently is the result of a birth trauma and suggests a 
serious brain lesion which may terminate in early death or result in 
spastic paralysis, or idiocy, or both. 

Etiology. — Infants and young children are peculiarly susceptible 
to convulsions because of lack of inhibitory control, due to insufficient 
development of the motor centers in the cortex, which, in conse- 
quence, discharge the more readily. A convulsion may be looked 
upon as a motor discharge affecting either the entire muscle structure 
or only a portion thereof. Convulsions, therefore, indicate cortical 
irritation. The irritation may be due to injury of the brain structure, 
as previously mentioned, birth trauma being the usual cause of convul- 
sions in the very young, or the convulsion may be the result of irritation 
from meningitis, tumors, hydrocephalus, or trauma in later life, such as 
a fall or blow on the head. 

Illustrative Case. — An infant of eleven months fell from his baby carriage to the 
stone pavement. Convulsions, repeated and severe, continued until the bleeding 
area in the cortex was located, the skull was opened, and the bleeding vessel was 
tied. 

Convulsions may be due to remote causes. 

Rachitis. — Rachitis, according to my observation, is a most fertile 
contributing cause. The reason for this is not clearly understood. 
Various theories have been advanced. Probably the nerve-centers 
share with other portions of the body in malnutrition and lack of de- 
velopment. In a rachitic the inhibitory control is of a very low order. 
In many rachitic children it is surprising how little irritation may bring 
on a seizure. 

Gastro-intestinal Causes. — An immense majority — over 90 per cent. 
— of the cases of convulsions coming under my notice have been due to 



484 THE PRACTICE OF PEDIATRICS 

gastro-intestinal disorder, most frequently in the form of acute indi- 
gestion due to unsuitable articles of diet. Rachitic children supplied 
many of these cases. 

If the irritation is sufficiently severe, convulsions may o.ccur in the 
most robust. Thus, a boy of three years had repeated convulsions un- 
til he was relieved of 43 large round- worms (lumbricoids). 

Convulsions of intestinal origin may be due either to the effects of 
toxins supplied by abnormal digestive processes, or to direct intestinal 
irritation. A case of the latter type was seen in the New York Infant 
Asylum, where a child had repeated convulsions and died in a seizure. 
At the autopsy a fourth of a small orange was found in the intestine. 

Thymus Gland. — Enlargement of this gland has been present in six 
cases of fatal convulsions. The majority of the cases have been seen 
in hospital work, where the enlargement of the thymus could be proved 
at autopsy. 

I have seen in private work two fatal cases presenting the same 
symptoms. 

Convulsions of toxic origin may usher in pneumonia, scarlet fever, 
or any of the acute infectious diseases. 

Particularly disturbing cases are the newly-born, who develop not 
convulsions but grimaces and slight twitchings of the face, with a 
tendency to stupor and irregular respirations, all very bad signs indeed 
in a newly-born baby. These cases may go on to the development 
of true convulsions, but many never show more active symptoms than 
those mentioned. Particularly unfavorable is it if these various 
manifestations are combined even to a mild degree. Sooner or later 
the child appears for treatment because of retarded mental develop- 
ment. 

Dr. W. Sharpe of New York has performed the decompression 
operation on several of these infants ; those with active nervous symp- 
toms, and those in which there was nothing but defective mentality 
with a suggestive early traumatic history. I have been surprised at 
the amount of lesions, hemorrhage, cysts, etc., which are to be found, 
with comparatively little attending reflex manifestations. 

Uremic convulsions are to be classed under this heading. 

Convulsions are frequently the termination of a prolonged broncho- 
pneumonia or enterocolitis. I have seen a large number of these cases 
in institution work. 

Heredity apparently plays but little part as regards predisposition. 

Dentition. — Dentition may indirectly be a cause in producing in- 
digestion, with resulting irritation and toxemia. I have had three 
patients who had convulsions with every tooth cut and without demon- 
strable associated digestive disorder. 

Phimosis. — Two boys had repeated convulsions which subsided 
when they were circumcised and relieved of much smegma and local 
irritation. 

Asphyxia. — A strong boy nine months of age was taken in bathing 
by his mother. A large wave enveloped and separated them. The 



INFANTILE CONVULSIONS 485 

baby was unconscious when found. With returning consciousness he 
passed into a convulsive state which lasted several hours. Evidently 
there was a cerebral hemorrhage, as the child is now an imbecile and 
had been perfectly normal before. 

Tetany (p. 491). — Severe convulsions, although exceptional, 
may be present in severe tetany. In tetany the manifestations are 
usually those of continuous tonic contractions. 

Repetition. — With each convulsion the inhibitory control is lessened, 
and each succeeding seizure requires less cortical irritation than its 
predecessor. Gowers states that 30 per cent, of the cases of epilepsy 
have their origin in so-called simple infantile convulsions. 

Manifestations. — Convulsions vary greatly in their manifestations. 
The seizure may be so slight as to be scarcely recognized. These are 
the so-called "inward" convulsions. There may be a momentary 
spasm of the body, with slight twitching of the face and extremities, 
after which the child appears normal or sleepy and dull for a few mo- 
ments. The convulsion, on the other hand, may be most intense and 
prolonged. The onset is sudden. There are usually twitchings of the 
muscles of the face and incoordinate movements of the extremities. 
There are alternate contractions and relaxations of all the muscles. 
The eyes become set, and the child is unconscious. There is frothing 
at the mouth, and the breathing is stertorous and labored. The child 
may rapidly pass out of the convulsive state or become quiet, with in- 
frequent twitchings, and thus remain for hours. In a fatal case the 
temperature was 111°F. — as high as my thermometer would register. 
The temperature was reduced, and the child lived eight hours, but 
never regained consciousness. 

In many instances the child passes from one convulsion into 
another. During active treatment, such as the hot bath and chloro- 
form administration, the seizure will apparently cease, and the child 
will show signs of returning consciousness. As soon as the treatment is 
discontinued the convulsion is again repeated. 

Prognosis. — I have seen a considerable number of cases of fatal 
convulsions, and do not look upon any attack with unconcern. The 
prognosis depends entirely upon the general condition of the patient 
and the direct cause of the convulsion. In the convulsions of scarlet 
fever, pneumonia, and gastro-enteric disease there is usually but little 
danger of life. If the attack is due to an enlarged thymus, the prognosis 
is unfavorable. 

A convulsion may be serious in its immediate, as well as in its re- 
mote, effects. One convulsion may produce cerebral hemorrhage, 
which may change the entire future of the patient, producing spastic 
paralysis or idiocy or both. About 10 per cent, of the cases of epilepsy 
originate in indigestion — the so-called "dentition convulsions." In 
these rachitis plays an important etiologic part. 

Under my observation several children under one year of age, in 
apparently good health, have died as the result of convulsions. In one 
case we found, upon autopsy, as above noted, one-fourth of an orange 



486 THE PRACTICE OF PEDIATRICS 

in the small intestine. In six the convulsions were due to enlarged 
thymus glands. In three of these cases there had been no previous 
symptoms indicating the existence of this condition. The patients 
were strong, robust infants. Two were breast-fed. The diagnosis 
was confirmed by autopsy in four cases, which included the breast-fed. 

Treatment. — Immediate Treatment. — When a convulsion occurs, 
the patient should at once be undressed and placed in a mustard bath 
(p. 780), at a temperature of 105°F. While in the bath, he should re- 
ceive brisk friction of the trunk, and particularly of the extremities. 
At the same time an attendant may give an injection of soap-water. In 
a great majority of the cases, in less than five minutes the child will show 
evidence of a return to consciousness. As soon as he can swallow, two 
teaspoonfuls of castor oil should be given. 

After a seizure the patient should be kept very quiet for twenty- 
four to forty-eight hours. An ice-bag or cold cloths should be applied 
to the head, and a guarded hot-water bottle kept at the feet. 

Diet. — The diet should be the lightest. Chicken broth, weak beef- 
tea, and thin gruels should constitute the nourishment for a day or two. 
A second seizure is more easily produced than the first, and a third 
easier than the second. 

The Use of Chloroform and Sedatives. — In case the attack is a very 
severe one, when the child is slow to respond or when he passes rapidly 
from one convulsion to another, chloroform inhalations, regardless of 
the age, should be given in sufficient quantity to prevent the seizures 
until the intestinal canal can be emptied, and sufficient sodium bromid 
and chloral can be given by mouth or rectum to prevent a recurrence. 

Rectal Medication.— To a child under one year of age 8 grains of 
sodium bromid and 3 grains of chloral may be given by rectum in 2 
ounces of mucilage of acacia. After the first year, from 3 to 5 grains 
of chloral may be given with 10 to 20 grains of sodium bromid. It is 
best to attach to the syringe a soft-rubber catheter, No. 18 American, 
or a small rectal tube. The catheter should be introduced for at least 
9 inches, so that the solution may be carried to the descending colon, 
where it will be retained better than if introduced with the small hard- 
rubber tip just within the anus. The bromid and chloral may be 
repeated at intervals of two to six hours, as required to control the 
convulsions, and continued in diminished doses as long as there are no- 
ticeable signs of nervous irritability, such as twitching and involuntary 
muscular contractions. 

Sedatives Internally Administered. — If the child can swallow, 5 
grains of sodium bromid in J-^ ounce of water may be given, and repeated 
at intervals of one to four hours, until the convulsions are controlled. 

Hypodermic Medication. — Morphin hypodermically is rarely re- 
quired. It should be used only when other means fail. A child one 
year of age may be given 3^:30 grain, and this may be repeated in two 
hours, though usually it will not be required. Under one year, 3^o to 
34 grain may be given; under six months, morphin should be omitted. 



LARYNGISMUS STRIDULUS 487 

LARYNGISMUS STRIDULUS 

. In laryngismus there is a spasm of the larynx involving the muscles 
of both inspiration and expiration. This rarely occurs after the eight- 
teenth month. I have seen it but a few times in older children. 

Etiology. — The part played by the thymus in laryngismus stridulus 
may be a very important role. 1 have seen two typical cases of laryn- 
gismus end fatally, with enlarged thymus as the cause of death. I 
require an ic-ray examination of every case of laryngismus. 

Morbid Anatomy. — No definite lesion has been found to account 
for the spasm, which occurs in association with a wide variety of morbid 
states, as well as without any apparent pathologic condition. 

Symptomatology. — The attacks are usually excited by some dis- 
turbance of the child's mental state. Thus, crying ushers in most of 
the paroxysms. The child attempts to draw in the breath preparatory 
to the cry, and the laryngeal spasm begins. There may be several 
short, whistling inspirations, each attempt being less successful than 
the first. The whole procedure requires but a few seconds. The face 
is first red, then blue and cyanosed. The absence of respiration con- 
tinues for an indefinite time — usually but a few seconds. Then the 
spasm subsides, and the child ''catches" his breath, which is signaled 
by a short inspiratory crow, followed by a series of longer and more suc- 
cessful inspirations. The child cries, the blood becomes oxygenated, 
the normal color returns, and all is well until the next attack. 

A patient three months of age had from twenty to thirty seizures a day, and the 
attacks ceased only with an improvement in the child's general condition. 

Laryngismus is very frequent in rachitic and poorly nourished 
children. The seizures are induced by fright or anger and the attacks 
cease in many instances, with spoiling the child, allowing him to have 
his own way, by improving his nutrition and in the use of tr. belladonna 
and bromides. If the thymus was the all-important factor in all cases, 
we would not expect a response to the treatment outlined. Further, 
autopsies on infants who have had laryngismus do not always show 
involvement of the thymus. We must continue to look for the expla- 
nation of many of our cases as belonging to the family of spasmophilics. 

The attacks may be milder or more severe than the foregoing. In 
the mild cases complete apnea does not take place. In others the laryn- 
geal spasm is complete from the onset. The child attempts to cry, 
and falls into what the mother calls "sl faint," becoming thoroughly 
relaxed and unconscious. Such attacks as these always cause me much 
anxiety, as they suggest strongly the possibility of enlarged thymus 
and sudden death. The period of unconsciousness may persist for a 
variable time, ranging from a few seconds to a minute or two. 

Congenital Laryngeal Stridor. — The obstruction is of a mild degree, 
present a greater part of the time. It is relieved by excitement and at 
its worst when the child is asleep. 

Diagnosis. — The diagnosis is made by the sudden onset of difiicult 
breathing, the rapid return to normal breathing, and the continuation 



488 THE PRACTICE OF PEDIATRICS 

of normal, unimpeded breathing between the attacks. In susceptible 
subjects the laryngismus may occur with whooping-cough and with 
acute catarrhal laryngitis. These diseases have a distinct symptoma- 
tology of their own, and need cause no confusion. 

Prognosis. — The prognosis in the main is good, but when one has 
seen sudden death in infants in private families and others in hospital 
work, all with spasmodic laryngeal association, he does not have the 
confidence in the outcome of a convulsion that is claimed by many 
writers. 

Duration. — Prompt results under treatment, except in mild cases, 
are the exception. The attacks may continue, varying widely in num- 
ber, for several weeks. The intervals between attacks lengthen and 
the attacks are less severe. 

Treatment. — Drugs. — The management is divided into two parts: 
the immediate relief of the spasm, and the treatment of the patient's 
debilitated physical condition, if such condition exists. From my 
observation, the most satisfactory method of relieving spasm in the 
mild cases — those in which the unconsciousness is of but a few seconds' 
duration — is by inverting the patient and at the same time slapping 
him on the back. Splashing cold water in the child's face may be of 
advantage in some cases, but I have found it of but little service. In 
cases which are sufficiently prolonged to resist inversion and slapping 
on the back, a quick resort to alternate hot and cold tub-baths, at 60°F. 
and 120°F. respectively, has been useful. If recovery is not prompt, 
intubation or tracheotomy should be performed, followed by attempts 
at artificial respiration. Between the attacks the patient should re- 
ceive small doses of antipyrin and sodium bromid. Under six months 
of age J^ grain of antipyrin and 2 grains of sodium bromid may be ad- 
ministered in 1 dram of cinnamon-water, 6 doses being given in twenty- 
four hours. From the age of twelve months to the third year, 1 to 2 
grains of antipyrin with 2 to 4 grains of sodium bromid may be admin- 
istered in 1 dram of cinnamon-water, 6 doses being given in twenty-four 
hours. The only disadvantage in the use of these drugs lies in the fact 
that these children may have faulty digestion, which condition may be 
aggravated by the sodium bromid. When this effect is observed, the 
bromid should be omitted and the antipyrin given alone. Antipyrin 
apparently never produces any unfavorable effects upon gastric 
digestion. 

Rectal Medication. — Colon medication may be of considerable serv- 
ice in these cases, and, when indicated, bromid and chloral are our 
most reliable sedatives. To a child of six months or under, 1 grain of 
chloral with 5 grains of sodium bromid may be given in 2 ounces of 
mucilage of acacia by the bowel; to a child of six to twelve months, 
2 grains of chloral and 8 grains of sodium bromid in 3 ounces of muci- 
lage of acacia; to a child of twelve to twenty-four months, 2 grains of 
chloral and 10 grains of sodium bromid may be given in 2 ounces of 
mucilage of acacia. The bromid and chloral should not be adminis- 
tered oftener than once in six hours. 



SPASMOPHILIA 489 

The method of administration is as follows: A large soft-rubber 
catheter or a .small rectal tube, attached to a Davidson syringe, should 
be introduced at least 9 inches into the rectum, so as to reach the de- 
scending colon. The child should rest on the left side, with the but- 
tocks elevated on a pillow so that they are higher than the shoulders. 
After the withdrawal of the tube the position of the child should be 
maintained for several minutes in order to aid in the retention of the 
fluid. 

All sources of reflex irritation should be removed. If difficult den- 
tition is a factor, the troublesome tooth should be brought through the 
gum. Adenoids, thread-worms, adherent prepuce, and constipation all 
should receive proper attention. Particularly must these children be 
kept free from all sources of mental excitement, such as loud talking, 
the overattention of adults, and the rough, active play of older children. 

Diet. — The dietetic management of debilitated, rachitic children 
suffering from laryngismus is the same as that of other debilitated 
children. (See ^Malnutrition, p. 92.) In general, they should be given 
as high a proteid diet as is compatible with their digestive powers. 
Thus, if there is intolerance of cow's milk given in suitable dilution, 
there should be no hesitation in advising the employment of a wet- 
nurse. If the proprietary foods are given they should be used with 
cow's milk. For children over one year of age cow's milk, cereals con- 
taining a large amount of nitrogen, such as oatmeal and soy-bean 
gruel, soft-boiled eggs, beef-juice, and scraped beef should form a large 
part of the diet. 

SPASMOPHILIA 

The term spasmophilia was originated by Finkelstein and is applied 
to a state of abnormal nervous irritability in infants, the expression of 
which is in one or more forms of spasm, principally holding the breath, 
convulsions, carpopedal spasm and laryngospasm. By some authors 
''spasmophilia" is used to designate only the latent form of this disease 
to which is applied the name tetany. 

Spasmophiha in all its forms is most common in bottle-fed infants 
after the third month. Heredity exerts some influence in the causation 
and several cases are not uncommon among children of the same 
parents. Spasmophilia and rickets are very closely associated and 
spasmophilia like rickets has been ascribed to a deficiency of lime salts 
in the sj^stem. Quest has demonstrated the existence of such a defi- 
ciency in the brains of children dying from tetany. ^Marriot and 
Rowland have shown a marked reduction of calcium in the blood of 
infants with marked cases, and McCallum and Voegtlin have shown 
the same condition in the blood of animals with experimental tetany 
induced b}^ extirpation of the parathyroids, thus confirming Escherich's 
view that the disease might be due to hemorrhages or other lesions in 
these glands. 

Toxemia from infectious diseases or digestive disorders conduces to 



490 THE PRACTICE OF PEDIATRICS 

outbreaks of spasmophilia, and most of the active manifestations 
are observed in the late winter and early spring. 

The pathological findings, apart from the presence occasionally of 
hemorrhages in the parathyroids, are the lesions of associated rickets. 

Symptoms. — ^Lowenburg conveniently divides spasmophilia into 
two types: latent spasmophilia and manifest spasmophilia. Latent 
spasmophilia is recognized by the presence of abnormal electrical re- 
actions together with reflex phenomena of nervous origin which may be 
elicited by mechanical stimulation. The amount of electrical current 
required to produce a kathodal opening contraction in the muscles of a 
spasmophilic infant is always less than the amount necessary to pro- 
duce the same reaction in a normal infant. Such response to a current 
of less than 5 milliamperes indicates positive spasmophilia. Chvostek's 
sign is an evanescent facial contraction elicited in spasmophilics after 
the second month of age, upon tapping the cheek just below the 
zygomatic process of the superior maxilla. Trousseau's sign is the 
occurrence of a characteristic carpal contraction in an extremity 
following ligation of the wrist or ankle in such manner as completely 
to occlude the blood supply. The peroneus phenomenon obtained by 
tapping the peronei muscles consists in a drawing up of the foot with 
the toes raised and slightly elevated. Theimich's lip sign consists in a 
protrusion or pouting of the lips, elicited by tapping the orbicularis 
oris. So-called manifest spasmophilia is characterized in addition by 
laryngospasm, carpopedal spasm, eclampsia or convulsions of a general 
character and by a peculiar induration (hard edema) of the hands 
and feet. The laryngospasm occurs upon slight disturbance of the 
child's nervous balance and may even occur during sleep. It is com- 
mon during fits of crying and differs from congenital stridor particu- 
larly in the peculiar crow which in spasmophilic laryngospasm follows 
a state of apnea and cyanosis of possibly a full minute's duration. 
Many attacks in one day are not uncommon. 

The carpopedal spasm consists in tonic contractions of the hands 
and feet. The larger joints are held flexed, the thumb adducted and 
the foot typically in a position of equinovarus. 

Eclampsia in spasmophilics is marked by the occurrence of clonic 
convulsions independent of brain lesions, nephritis and epilepsy. 

The hard edema of the hands and feet is supposedly a vasomotor 
phenomenon. 

Diagnosis. — Among the conditions frequently confounded with 
spasmophilia are epilepsy, tetanus, pertussis, enlarged thymus, con- 
genital stridor, laryngeal stridor and retropharyngeal abscess. Of 
these, epilepsy is most difficult to exclude. The typical reflexes and 
electrical reactions of spasmophiha are of the greatest value for differen- 
tiation in doubtful cases. 

Prognosis. — Under intelligent care and feeding the outlook is good. 
Progress may be confirmed by the observance of a steadily closer and 
closer approximation to the normal in reflexes and electrical response. 

Treatment. — Maternal nursing and wet nursing are of greatest 



TETANY 491 

value not only in preventing tetany but in limiting its progress. Holt 
affirms that to infants under eight months of age who give symptoms of 
tetany woman's milk should be supplied if possible. Aside from this 
the fundamental management of spasmophilia is essentially that of 
rickets. Most cases do well on cod liver oil provided the oil can be 
borne by the digestion and is best given about half an hour after the 
feeding. Calcium bromid in simple solution is generally recommended 
as the sedative of choice. The dose of the salt should be sufficient 
to control the spasm and may vary from 20 to 40 grains daily. Where 
this is unobtainable or ineffective, chloral, chloroform or even morphine 
hypodermatically, in dosage up to J^oo grain, may be given. Gastric 
and intestinal lavage are of value when there has been overloading of 
the digestive tract or toxic absorption therefrom, and when there are 
general convulsions or pronounced spasms of the extremities, warm 
baths are to be employed. 

CONGENITAL STRIDOR 

Attention was first called to this disease bj^ Rilliet and Barthez in 
1853. The condition is characterized by an inspiratory crow, slight in 
character but fairly constant when the child is quiet and asleep. It 
usually disappears under stress such as crying. The sound produced 
has been variously described as a crow, a cluck, a croak, etc. 

It appears at birth, or within a few days and continues for months. 
In a very pronounced case under my observation, the stridor contin- 
ued until the child was 18 months of age. So noisy was the breathing 
during sleep that it could be heard in an adjoining room with the doors 
closed. As a rule the stridor gradually lessens and ceases before the 
child is 1 year of age. 

Etiology. — Various explanations have been offered as to the cause of 
the stridor. It is probably due to a bilateral abductor insufficiency, 
a general relaxation of the larynx with the result that during inspiration 
there is a partial collapse of the muscular equipment and the lumen of 
the larynx is narrowed in consequence. As the child grows older the 
parts enlarge, the tissues become firmer and a better nerve control is 
established and the inspiratory obstruction is gradually relieved. 

Differential Diagnosis. — So characteristic is congenital stridor that 
one can hardly become confused with anything else. Beginning at 
birth and continuing with but little intermission in pronounced cases, 
it is most pronounced when the child is quiet and when asleep. It 
disappears under stress. There is no hoarseness ; no air-hunger. The 
obstruction involves inspiration only and is not sufficient to produce 
discomfort. 

Treatment. — No treatment is required. 

TETANY 

Tetany is a condition characterized by persistent tonic contractions 
of the muscles, usually of the upper and lower extremities. In rare 
instances cases will be seen in which the peculiar tonic contraction in- 
volves all the muscles of the body. 



492 THE PRACTICE OF PEDIATRICS 

Age. — Tetany is rarely seen after the second year, though cases are 
occasionally reported as occurring in older children. 

Tetany is most commonly seen in marasmic infants suffering from 
intestinal derangements of a not very active type. Occasionally it 
occurs in well-nourished children. 

Etiology. — In the great majority of instances tetany occurs in in- 
fants suffering from malnutrition and under one year of age. Rachitis 
has been present in the majority of my cases. In all cases seen by me 
malnutrition or pronounced digestive disturbance has been present. 

Illustrative Case. — A baby three months of age was given a high fat mixture 
(7 per cent.) in order to supplement the mother's milk. After a few feedings the 
child developed convulsions, with the typical tonic contractions. Under treatment 
the mental condition cleared, but general muscle contractions continued, which 
evidently caused great pain. The child was absolutely rigid, with both the lower 
and the upper extremities in the characteristic position, which continued for several 
days. 

The actual cause of this disease is still obscure, but from time 
to time new light is being thrown upon the subject. The majority of 
the cases are seen during the winter and early spring months, and, 
owing to this fact, Kassowitz's theory of a respiratory infection has 
received strong confirmation. Escherich, Ganghofner, and others 
have found that manifest tetany and laryngospasm in children increase 
during the beginning of winter, and gradually reach their highest point 
in February and March, after which they diminish in frequency until 
midsummer, when the incidence is practically zero. Escherich's 
statistical table of 240 cases shows : 

Month I II III IV V VI VII VIII IX X XI XII 

Number of cases 29 51 59 45 10 7 14 2 21 16 

In a recent, rather extensive work, V^ilcox, of New York, found 
that during the months of December, January, and February, he ob- 
tained the greatest number of middle-grade reactions, while three of 
his cases of frank tetany occurred in February and two each in Decem- 
ber and January. The incidence of hyperirritability was greatest in 
December. 

It appears, from the literature on the subject, that the frequency 
of tetany varies considerably in different countries and cities; in some 
localities the cases are almost frequent enough at least to suggest an 
epidemic. In infancy males seem to be more frequently affected than 
females. 

According to Fischl, fully 63 per cent, are rachitic; this, of course, 
will vary in different countries. Kassowitz has demonstrated the 
similar relation to the time of year existing between the incidence of 
tetany and that of the rachitic affections. He came to the conclusion 
that there must be an intimate relation between the two. Wilcox 
concludes that the child's irritability varies directly with the general 
condition of nutrition, and that the well-developed and nourished 
respond much less readily to galvanism than those underfed and below 
the normal weight. 



TETANY 493 

Seligmuller, Pott, Thiemich, and others are convinced that spas- 
mophiha (tetany, laryngospasm, and eclampsia infantum) possesses in 
a well-marked degree the characteristics of heredity. Thiemich's deci- 
sion has come from a dozen observations at the Breslau Kinderklinik 
relating to families in which the mother had laryngospasm or eclampsia 
in her childhood, and still shows a pronounced facial phenomenon as 
a residuary latent symptom. 

Cold, intestinal parasites, bowel infections, chronic intestinal dis- 
turbances (of which there were fully 73 per cent, in Fischl's cases), and 
an enlarged thymus, have all, in turn, been regarded as causative fac- 
tors. Concerning the latter theory, which was advanced by Paltauf, 
one must consider the contrast existing between the pasty 'lymphatic " 
type and the lean and imperfectly developed child, in which the evi- 
dences of the spasmophilic diathesis are almost solely found. 

It seems improbable that the disturbance has anything to do with 
the sugar, fat, or protein, since no harm results by adding any of these 
substances to a diet consisting of carbohydrates, which tend to diminish 
irritability. On the other hand, whey acts precisely as does cow's 
milk in increasing both mechanical and electric irritability, and it 
might be supposed that it contains in solution a substance which is 
concerned in the production of the symptoms. 

Considerable evidence has been accumulated of late concerning 
calcium metabolism and its relation to tetany. So far the conclusions 
arrived at by different observers vary,. but, nevertheless, there are a 
few points on which a unanimous opinion exists. Experiments in 
physiology have shown that the peripheral nerve irritability can be in- 
fluenced by salt solutions, and only lately have the researches of Holb 
shown that it is not one salt alone, but the interaction with other salts, 
which influences nerve irritability; either a diminution of the sodium 
or an increase of the calcium diminishes irritability. This fact has 
suggested that the etiology existed in salt metabolism. 

Due to these observations, Czerny commenced some experiments 
on the chemical examination of brains, which were carried out by 
West, who showed that there was a diminution of the calcium content 
of the brains of children with tetany; he further pointed out that, by 
feeding calcium-poor food to dogs, the irritability of the peripheral 
nerves was diminished, while Sabbatini demonstrated that the applica- 
tion of calcium to the cortex diminished the electric excitability. 
Stoeltzner, attempting to repeat these observations, obtained some- 
what contradictory results. Rosenstern, along with other observers, 
approached the subject from the clinical aspect and fed calcium salts 
in cases of the spasmophilic diathesis, producing a remarkable diminu- 
tion in the nerve irritability, the effect of which disappeared in twenty- 
four hours, the same results being obtainable, only more rapidly, by 
the intravenous injection of the calcium salts. 

An examination of the blood in this condition has shown a consider- 
able diminution of the salt, while, on the other hand, there is known to 
exist an increased output of calcium in the urine and feces. Similar 



494 



THE PRACTICE OF PEDIATRICS 



results have been obtained in this country by McCallum and VoegtHn 
in experiments on parathyroidectomized dogs. Further explanation 
is offered in postoperative tetany in adults. When the parathyroids 
have been wholly or partially removed, the symptoms ensuing are 
relieved by the administration of calcium by mouth, the effect passing 
off in a few hours. In infantile tetany little result has been obtained 
by the administration of calcium by mouth. 

Pathology. — No constant lesions have been located that may be 
associated with tetany. Thus far no uniform anatomic changes in the 
parathyroids have been reported. The most usual findings are hemor- 
rhage, recent or old; cysts, and staining. Fischl, in a somewhat recent 
article, published the postmortem findings in his fatal cases. He 
found tuberculous meningitis, bronchopneumonia, hemorrhagic infil- 
tration of the brain, edema, and chronic intestinal inflammation. In 

one case seen by me there 
was a pachymeningitis. 
Autopsies on other infants 
in whom tetany was present 
failed to reveal any dis- 
eased condition of the 
nervous system. 

Symptoms. — The ap- 
pearance of a child with 
tetany is characteristic. 
The symptoms vary only 
in their intensity. 

In mild cases there may 
be simply an adduction of 
the thumb on the palm of 
the hand, giving rise to 
the term the ''accoucheur 
hand." With this phe- 
nomenon there will usually be an extension of the feet, caused by 
marked contraction of the tendo Achillis. 

In the more pronounced cases the hands are flexed on the arms, 
and the fingers are lightly contracted over the adducted thumb (Fig. 
62). The feet are held in a marked extended position, with the toes 
flexed toward the plantar surface of the foot. With the second and 
third row of phalanges extended, a similar phenomenon is also some- 
times seen in the fingers. Usually the joints at the elbow, shoulder, 
hip, and knee may be moved without discomfort. Attempts at forcing 
the other joints to the normal position are met with resistance and 
evidence of pain. The knee-jerk is markedly exaggerated. There is 
an increased response to both the galvanic and faradic current. Mus- 
cle irritation may or may not cause various phenomena. Trismus has 
never been present in my cases. 

Muscle Irritability. — Evidence of muscle and mechanical irritability 
may be demonstrated in the following ways: 




Fig. 62. — Hand in tetany. 



TETANY 495 

The Chvostek sign depends on the heightened irritabihty of the facial 
plexus (some believe it to be reflex), which, on being tapped with the 
finger or a percussion-hammer midway between the zygoma and the 
angle of the mouth, produces a contraction at the ala of the nostril, 
the angle of the mouth, and, in marked cases, the inner canthus of the 
eye and eyebrow. This symptom is given various grades of impor- 
tance by authors. Thiemich's conclusions are that ^Hhe facial should 
be stricken from the list of nervous stigmas, and must be regarded even 
in late childhood as a pathognomonic sign of latent tetany, even if this 
disease remains continuously a symptomless anomaly of the nervous 
system." This sign was found in but one of Wilcox's cases, and it will 
be found in perhaps half of all cases. 

Schultz^s sign is produced by stroking the skin over the zygoma, 
which in extreme cases of tetany produces a contraction similar to the 
Chvostek. In comparatively few cases can this sign be demonstrated. 

Trousseau's Sign. — Shutting off the blood-supply in the elbow or 
groin, through pressure, is followed, after a varying interval, by the 
typical carpal or pedal spasm. 

Duration. — The condition, under my observation, has lasted from 
a day or two to two to six weeks. A return to the normal is usually 
slow. Cases that are entirely relieved in less than a week are extremely 
rare. When the disease disappears rapidly, we are not sure that it 
may not return, possibly in a more severe form. 

Diagnosis. — The diagnosis is not at all difficult, and is made by the 
characteristic contraction of the hands and feet, which occurs in no 
other condition. While perhaps the nervous phenomena might sug- 
gest cerebral disease, the absence of mental symptoms excludes it. 

Electric Irritability. — In tetany the electric reactions may be said 
to be of distinct diagnostic value. It seems very difficult to establish 
exactly normal reactions for children, as many will react low one day 
and high another, and then again the reactions vary with changes in 
the digestive and metabolic processes. It must be kept in mind that 
the electric reactions are not always diagnostic of tetany, but, on the 
other hand, there is now no doubt that, by this method of diagnosis, 
cases hitherto not suspected of tetany may be brought to correct diag- 
nosis. Just what exact electric findings are essential to a diagnosis 
is still a matter of dispute. Escherich believed that in normal children 
only, KCC appears under 5, and that only occasionally may anodal 
closure be present with this current strength. 

Wilcox cites the grades of electric irritability: 

1. Normal, in which KCC occurs under 5. Sometimes ACC is 
found at 5 or just below it. 

2. The middle grade, or anodal hyperirritability, in which KCC is 
less than 5, and AOC is less than ACC and less than 5. 

3. Tetany, in which all four reactions are less than 5. A suggestive 
tetany is the occurrence of AOC less than ACC and the appearance of 
KCC tetanus. 

The incidence of tetany varies, due presumably to the varying at- 



496 THE PRACTICE OF PEDIATRICS 

titudes of the observers as to what constitutes a true diagnosis. Num- 
erous authors give figures varying from 6 per cent, down to 0.7 per 
cent, in artificially fed children under three years of age. 

Technic. — The simplest and most efficient instrument is one sup- 
plied by Wappler and Co., of New York. It consists of dry cells which 
supply a galvanic current and contain a switch for reversing the polar- 
ity, a rheostat for controlHng the current and a balanced milliampere- 
meter measuring from 0.2 to 10 milliamperes. 

The patient is laid in bed with the feet directed toward the observer, 
who grasps the right foot with the left hand, in such a manner as to 
be able to detect the slightest response occurring in the flexor tendons 
or the ankle or toes. The negative electrode is placed upon the ab- 
domen of the patient, while the positive one is controlled by the righfc 
hand of the operator, who at the same time regulates the rheostat with 
his elbow. The test should always be begun with a current strength 
sufficient to produce muscle response and then gradually reduced. If 
the opposite is attempted, the lowest point will invariably be passed. 
One should always consider the individual skin resistance, which varies 
directly with the amount of fat and is rapidly reduced as the test 
progresses. 

Prognosis. — The prognosis depends entirely upon the condition 
which accounts for the tetany, which is to be looked upon as a symp- 
tom and not a disease. The eclampsia case, to which I have already 
referred, came near a fatal termination. 

Fatal cases have been recorded as occurring with thj-^mus gland 
involvement, and here again we have enlarged thymus as a cause of 
death. 

Treatment. — Inasmuch as intestinal toxemia and malnutrition are 
apparently important agencies in causing the phenomena, attention 
directed to the intestinal canal and nutrition is indicated. The child 
should be given 2 drams of castor oil, and milk "should be excluded 
from the diet for a day or two until the stools become normal. This 
treatment alone has cleared up some of my cases. When the spasm 
persists, bromid of soda should be given in 2-grain doses every two 
hours, at least 6 doses in twenty-four hours being given to a child one 
year of age or younger. Calcium bromid appears to be of some service 
in controlling the symptoms in 5- or 10-grain doses 4 times daily. 

Whether the benefit is due to the sedative action of the bromid 
alone or the possibility that some of the calcium given is retained as 
such, is an open question. No satisfactory metabolic experiments 
have been made to show that such retention takes place when calcium 
is administered through the alimentary tract. No unpleasant effect 
has been observed from the use of the drug. In a recent case there was 
decided retention of sodium chlorid. This was relieved by free cathar- 
sis and the use of urea, 15 grains daily in the food. The child recovered 
in two weeks. 

The patient should be kept very quiet during an attack, as undue 
excitement may precipitate an attack of laryngismus stridulus or con- 



INSANITY IN CHILDREN 497 

vulsions, which may be of a very serious nature. A hot bath at 110°F. 
for a few moments, repeated at six-hour intervals, will often have the 
desired relaxing effect. 

The later treatment consists in regulating the child's nutrition. If 
the malnutrition is extreme, or if the infant is under six months of 
age, a wet-nurse affords the safest means of nutrition. A wet-nurse, 
however, is not practicable for children over one year of age. There 
is, moreover, considerable uncertainty as to how older infants ap- 
proaching the twelfth month will take the breast. When employment 
of the wet-nurse is impossible or impracticable, an adjustment of the 
food to the child's digestive capacity is demanded along the lines laid 
down in the section on Malnutrition. 

Proteid Diet. — Not a few of the infants who develop tetany have 
had food poor in proteid, such as is furnished by the proprietary foods 
and condensed milk, or they may have had a low proteid capacity, 
which, as far as the nutrition is concerned, amounts to practically the 
same thing. The proteid elements in the diet, therefore, should be 
kept well in mind in feeding these cases. It is in such cases that pep- 
tonized milk and malt soup (pp. 68 and 94) are indicated. The milk 
should always be given raw, unless the patient's station in life or the 
season of the year forbids. If the milk is heated, as is necessary in 
malt-soup feeding, orange or beef-juice should be given at the same 
time. 

Climate. — When possible, children who have had tetany should in 
every instance be given the advantages furnished by climate. An 
outdoor life in the country, with open windows at night, is necessary 
for rapid relief of the weakened physical condition which underlies the 
disorder. 

Bath and Oil Inunctions. — The patient should be given a brine bath 
(p. 780) at bedtime. This is to be followed by inunction with an ani- 
mal fat during the cooler months, goose-oil or fresh lard being preferred. 

Tonics. — As these patients are usually suffering from a secondary 
anemia, }'2 grain of citrate of iron and ammonium may be given two 
or three times daily after feeding. The hygienic and dietetic manage- 
ment of tetany is practically the same as that suggested for marasmus 
and malnutrition. 

INSANITY IN CHILDREN 

Insanity in children, implying a completely developed functional 
mental disorder, is very infrequent. When it occurs, its existence may 
most frequently be traced to hereditary influence. This need not im- 
ply the existence of actual insanity in the patient's ancestors, but, in 
many instances, only pronounced neuropathic diathesis, the effects of 
which are apparent under conditions of excitement and stress. In cer- 
tain families there may be a gradual deterioration of the character 
described by Kirchoff: ''In the first generation we find, apart from 
nervous symptoms, the disappearance of ethical feelings; then follows 
a generation in which the tendency to excesses appears, and the danger 
32 



498 THE PRACTICE OF PEDIATRICS 

is then greatly increased by alcoholism. In the third generation there 
is perhaps suicide, or an affective form of insanity, and finally more 
profound mental disorders appear, such as congenital idiocy." 

Probably no less important than heredity are the environment and 
the early associations of the patient. A child's mental processes are 
closely dependent on sensory impressions and the affections of pleasure 
and pain. Desires are inherent, but active volition and self-control 
are faculties of slow development. Under these conditions phe- 
nomena, such as fright, illness, injury, or neglect, exert a greatly 
augmented influence. The period of puberty, moreover, is responsible 
for perversions, emotional outbreaks, and other manifestations of 
instability, which explain the origin of a large group of cases of 
mental aberration. 

Thus, in any individual of neurotic temperament subjected to bodily 
suffering, overwork, or mental strain, during the period of growth, 
insanity may occur, and its relative infrequency can be explained only 
by the remarkable recuperative possibilities of this period. 

Imperative Concepts; Morbid Fears. — These constitute the sim- 
plest psychic disorders of childhood, and are extremely common and 
of great diversity, ranging from simple incapacity to resist the fasci- 
nation of deep water and high places, to uncontrollable fears of darkness 
or open places and crowds (agoraphohia) or lightning and storms 
(astraphohia) , Occasionally the child may become overwhelmed by 
some impulse too great for him to resist, and develop a definite " craze." 
The most common forms of this are kleptomania, pyromania, and 
dromomania. Of these, the ''running away" impulse is perhaps 
oftenest recognized as something for which the subject is not fully 
responsible. 

Neurasthenia is much less common in children than in adults, but 
may develop in children of neurotic ancestry amid any conditions 
which produce mental or bodily fatigue. Too long school periods, 
excessive social demands at home, and late hours are among the most 
common causes, especially in the case of poorly developed children. 
The usual symptoms of chronic irritability, sleeplessness, and ^' moods" 
may give way at last to a state of true hypochondriasis. 

Hysteria in its more pronounced forms should be distinguished 
from mere laughing and crying spells, which children frequently exhibit 
without complete loss of control. Nevertheless, ''in all hysteric sub- 
jects," according to Sachs, there is "not so much a direct lack of 
power to exert the will as a tendency to exert it in perverse fashion." 
Occasionally, after a period of severe stress, a child may develop 
hysteric mania. This occurs occasionally in girls on the establish- 
ment of menstruation. In cases of true hysteria, sensory and motor 
disturbances are common, and occasionally hystero-epileptic attacks 
may occur. 

Melancholia is frequent in children, and may assume a serious form, 
characterized by the development of suicidal tendencies. In most 
instances, however, the prognosis for recovery is good. 



MALFORMATIONS OF THE BRAIN AND CORD 



499 



Mania unrelated to hysteria may be induced by great excitement, 
fright, or febrile diseases. The influence of puberty upon the develop- 
ment of the condition in girls has been noted. Under symptomatic 
measures involving enforced rest and quiet, maniacal cases in the young 
usually terminate in recovery after a few months. 

Dementia prsecox, though not a disease of childhood, is common 
after the twelfth year. Hebephrenic, katatonic, and paranoid types 
are described. The frequency of a prodromal period marked only by 
neurasthenia and hypochondriasis should be remembered. 

Treatment. — The treatment of the psychic disorders of childhood 
is comparatively simple. Under a firm but quiet home regime, with 
proper attention to existing physical defects, the milder cases of de- 
rangement ordinarily respond favorably. Punishment for the persist- 
ence of ideas and fears for which the patient is not directly accounta- 
ble may do great harm. Hysteric symptoms of considerable duration 
may, however, yield readily to the right sort of sensory or psychic 
^'surprise." Suggestion has a very wide field in the treatment of 
children. 

In the more severe forms of mania, isolation, close supervision, rest, 
and hydrotherapy afford good results. 

A properly functionating digestive tract and a good supply of 
hemoglobin and red corpuscles are essential to the preservation of a 
normal mentality in any child, regardless of heredity or environment. 



MALFORMATIONS OF THE BRAIN AND CORD 

The various types 

of cerebral malforma- 
tion are of develop- 
mental rather than of 
chnical interest. 

Meningocele, en- 
cephalocele, and hy- 
drencephalocele are 
protrusions of cranial 
contents through con- 
genital gaps which per- 
sist between the bones 
of the skull. Such de- 
fects are most com- 
mon in the occipital 
and frontonasal re- 
gions. 

When the protrud- 
ing sac consists only of 
the membranes sur- 
rounding the brain, it is called a meningocele; when a portion of the 
brain itself is included, the tumor is called an encephalocele; and when 
the encephalocele contains ventricular fluid a hydrencephalocele. 




Fig. 63. — Meningocele. 



500 



THE PRACTICE OF PEDIATRICS 



In microcephalus (see Fig. 64) the capacity of the skull is less 
than normal, and the brain itself is abnormally small. This defective 
development has been explained by Virchow's theory of premature 
ossification in the cranial bones, but according to Sachs, is proba- 
bly due to atrophic changes, which are the result of hemorrhage 
or inflammation affecting the brain and its membranes. If the latter 
be the true explanation of the deformity, any treatment of an operative 
character to allow brain expansion by increasing the dimensions of the 
skull must promise little. 

Neither explanation is satisfactory. There is more than a prema- 
ture ossification. The 
skull formation along 
the hne of sutures is 
excessive. In many 
cases I have found at 
the line of the suture 
a distinct ridge, as 
though nature had 
taxed herself to the 
utmost to unite the 
cranial bones. The 
ductless glands prob- 
ably are a factor in the 
over-development. 
With the excessive 
ossification at the 
sutures the bones of 
the skull generally are 
much thicker than 
normal. 

Symptomatology. — 
The symptomatology 
Palsy. The patients 




Microcephalic idiot. 



is the same as described under Cerebral 
are almost always low-grade defectives. 

In subjects with microcephalus — microcephalic idiots — who survive 
infancy, symptoms of paralysis, lack of development of the special 
senses, and low intelligence are the rule. 

Craniectomy. — The operation of craniectomy, based upon the 
theory that the condition is due to a premature ossification of the 
skull, was much in vogue several years ago. It was usually unpro- 
ductive of beneficial results, and has been discarded. Craniectomy was 
performed on an imbecile boy of four years of age who was under my 
care at the New York Infant Asylum. After the operation he received 
more care and attention than before, and he seemed to develop some- 
what along mental lines, but when the attention was later withheld, 
he relapsed into the former condition. 

Porencephalus is a condition characterized by the existence of a 
hole in the brain substance. This abnormality may be congenital or 



MALFORMATIONS OF THE BRAIN AND CORD 501 

acquired. The congenital form may develop from atraumatic enceph- 
alitis during intra-uterine life. The acquired form is usually due to 
meningeal hemorrhage. The cavity in porencephalus commonly in- 
volves the motor areas of the cerebrum and extends into the lateral 
ventricle. According to Dana, true porencephalus due to a congenital 
defect in nutrition occurs in about one-fourth the cases of cerebral 
palsies in children. 

Cyclops, hemicephalus, anencephalus, and malformations of in- 
dividual lobes of the brain belong to the domain of embryology and 
neurology, rather than to general pediatrics. The terms themselves 
roughly define the respective conditions. 

Spina Bifida. — Spina bifida is the term applied to a congenital 
cleft in the vertebral column which permits of a hernia of part of the 




Fig. 65. — Spina bifida. 

contents of the canal. The defect is found most frequentlj^ in the 
cervical or lower lumbar vertebrse. 

In meningocele of the cord the membranes alone constitute the hernia 
sac. 

Myelomeningocele is a protrusion of a portion of the spinal cord and 
its attached nerve-roots, together with an accumulation of fluid, which 
usually has its origin in the anterior subarachnoid space. 

In syringomyelocele, hydro myelocele, or myelocystocele the central 
canal of the cord is dilated with fluid, and the cord substance itself 
forms the lining of the sac. 

The malformations just described are frequently accompanied by 
other abnormalities in the same subject, such as hydrocephalus, club- 
foot, sensor}^ and trophic disturbances and exstrophy of the bladder. 
With myelomeningocele and syringomyelocele, paralysis of the ex- 
tremities, bladder, and rectum may exist. 

Diagnosis of the type of spina biflda present in a given case is not 
always easy. 

Simple spinal meningocele is frequently found in the sacral region. 
This tumor is often translucent. It protrudes through a small cleft 
in the canal and is pedunculated. It is seldom associated with symp- 
toms of paralysis. 



502 THE PRACTICE OF PEDIATRICS 

In myelomeningocele and syringomyelocele the swelling is ordi- 
narily less transparent and has a broader base. Pressure on the tumor 
may cause distention of the fontanel. These forms commonly occur 
in the lumbosacral region, but may exist in any region of the spine. 
Paralytic symptoms are much more common than in cases of 
meningocele. 

Of the three forms, syringomyelocele is far the most frequently 
associated with a hydrocephalus. 

. Prognosis. — Simple meningocele offers a fair prognosis under treat- 
ment. Some cases even terminate favorably by spontaneous rupture 
of the sac and closure of the cleft in the spine. 

In other instances operation may be followed by complete recovery, 
although in about one-third of the cases the operation is followed by 
an acute hydrocephalus. 

In a very recent case of a child two months of age the beginning of hydroceph- 
alus was apparent ten days after the removal of the meningocele. 

The two other forms of spina bifida are very unpromising, and under the best 
therapeutic measures usually result fatally. 

Treatment. — The results of treatment of spina bifida, regardless of 
its type or the method employed, will scarcely warrant us in promising 
parents much in the way of improvement. In my hands the injection 
of iodin has not been of any value. The pressure treatment is unsatis- 
factory. Surgery promises better results than does any other treat- 
ment. Operative measures are fully described in works on surgery, 
and the results are sometimes brilliant. Bo-called cured cases, how- 
ever, often develop internal hydrocephalus, so that the latter condi- 
tion is worse than the original. Operations, further, are not without 
immediate danger, for in a great majority of cases portions of the cord 
are within the sac, the excision of which may result in permanent paraly- 
sis and deformity. It is the duty of the physician to see that the tumor 
is carefully protected and kept clean, and that the child is properly 
nourished until such time as a suitable operation is thought advisable. 

TYPE AND INCIDENCE OF BRAIN TUMOR 

Tuberculous tumors are by far the most frequent form of intra- 
cranial neoplasms occurring in childhood. More than 50 per cent, of 
all brain growths belong to this type. Next in order of frequency are 
gliomata, gliosarcomata, and sarcomata, while adenomata, fibromata, 
angiosarcomata, cholesteomata, and gummata are all rare in children, 
carcinomata being exceedingly rare. 

Cysts of the brain resulting from an old hemorrhage or from embolic 
softening may simulate the symptoms of a growing neoplasm if the 
cyst contents become suddenly increased. Parasitic cysts of the 
brain (echinococcus or cysticercus) are not unknown in children. 

Brain tumors may be congenital, or they may develop at any time 
after birth. Gowers observed 18.5 per cent, in the first ten years and 
14 per cent, in the second decade of life. 



I 



MONGOLIAN IDIOCY 503 

MENTALLY DEFICIENT CHILDREN (IMBECILITY; IDIOCY) 

It is not desirable, even were it possible, to make a differentiation 
of the various types of mentally defective children. Mongolian idiocy, 
cretinism, and amaurotic family idiocy are distinctive types, each 
type having characteristics of its own sufficient to demand a distinct 
classification. All other forms are so variable in their etiology and 
the degree of impairment which they produce that any separate group- 
ing is impossible. Thus we see idiocy due to microcephalus (see Fig. 
64), to hydrocephalus, to antenatal defects, to birth trauma, and to 
meningitis, particularly of the cerebrospinal form. 

Besides microcephalic, hydrocephalic, Mongolian, amaurotic family, 
and cretinoid idiocy, there is a form of idiocy in which the brain shows 
sclerotic areas in the cortex. These may be due to hemorrhage at 
birth. Cerebrospinal meningitis complicated by encephalitis may also 
be responsible for the sclerosis. Finally there may be porencephalus, a 
smaller or larger defect in a cerebral hemisphere, either of congenital 
origin or due to hemorrhage at birth or later. 

Unclassified Cases. — Epilepsy in early life tends to mental im- 
pairment, and may eventually result in idiocy. I have repeatedly 
seen cases in which no cause whatsoever could be demonstrated to 
explain the condition. 

The brain, although a most important organ, is very ineffectively 
protected until the child is well on in the third year. If the facts in 
each case were known, it would probably be discovered that brain 
trauma at birth was the cause of idiocy in a large majority of the un- 
classified cases. Syphilis, consanguineous marriages, and alcoholism 
are looked upon as etiologic factors by many authors. The mental 
improvement varies within wide limits, and the cases range from those 
of complete idiocy to those in which it is impossible to determine 
whether the patient is within or without the group which is looked 
upon as normal. Mental impairment is often associated with spastic 
paralysis; the majority of the unclassified cases show such association. 
Nevertheless, in the examination of hundreds of cases in institutions, 
many defectives will be found in whom there is no evidence of muscle 
involvement. 

Mentally defective children are described as backward, feeble- 
minded, children of retarded development, imbeciles, and idiots. In 
a legal sense all are imbeciles who cannot appreciate right and wrong. 
Idiots show complete absence of responsibility. 

Defective sight and hearing may place a child, naturally not men- 
tally keen, in the defective class. 

MONGOLIAN IDIOCY 

The Mongolian type (Figs. 66, 67, and 68) is found with very few 
exceptions only in the Caucasian race, and received its designation 
because of the facial resemblance to the Mongolian. 

Etiology. — Mongolianism is of congenital origin. There is no known 
cause. Debility in parents seems to play an important part. They 



504 THE PRACTICE OF PEDIATRICS 

are found among the first born of old parents, the first born of very 
young parents. They are apt to represent the 5th, 6th or 7th preg- 
nancy. They may also be the 1st or 2d pregnancy of perfectly 
normal parents. This, however, is unusual. In these cases, as in 
cretinism, it will probably be discovered in the future that we are 
dealing with a ductless gland defection. Whatever may be the 
cause, it is identical in all, for all Mongols are alike in form, feature, 
intelligence and the many characteristics that go to form the symptom 
complex of Mongolism; this regardless of race, social position, age or 
physical condition of the parents. Whatever may be the basic 
error, it is the same in all and it is not due to syphilis. 

Pathology. — Besides the Mongolian type of face, the microcephalic 
skull and the retarded bone growth are characteristic of the disease. 

Mongolian idiots at autopsy show 
the evidence of faulty development 
of the brain cortex. The entire 
brain is smaller and lighter in weight 
than is normal, and fissuration is 
defective. Congenital cardiac mal- 
formation is not infrequent in these 
cases, a patent ductus arteriosus or 
an incomplete ventricular septum 
being the commonest lesions found. 
Other visceral malformations occur 
less frequently, but stigmata of de- 
generation are very numerous, 
especially of the palate, ears, and 
fingers. 
66.— Mongolian idiocy. Symptomatology .—The face is 

usually defective in expression, broad 
and flat, the nose small and broad at the base, the eyes wider apart than 
in the normal child. In rare cases, the face will show a considerable 
degree of intelligence (Fig. 67), and is usually round and full. The 
eyes are prominent and placed obliquely, with the palpebral fissures 
extending in an upward direction, elevating the outer canthus. The 
skull shows anteroposterior narrowing, which, together with the promi- 
nence of the upper cervical vertebra, causes a marked narrowing of the 
nasopharyngeal vault. This is readily appreciated on examining the 
subject for adenoids, which are supposed to exist because of the habit 
of the open mouth and mouth-breathing. The tongue is usually large, 
and protrudes during a greater part of the time. The muscles of the 
arms and legs are soft, the skin is usually rather dry and bluish, and 
there is a tendency to coldness of the extremities. The joints are re- 
laxed and the ears are crumpled. There is a distinct inward curve of 
little fingers particularly of the third phalanx. The occiput is flat. 
The children have a vacant, stupid expression, and are unusually good- 
natured. They cry much less than normal children. They are feeble, 
and a great majority die before they are three years of age. They are 




MONGOLIAN IDIOCY 



505 



particularly subject to respiratory and intestinal diseases. A few grow 
to adult life. In an institution for the feeble-minded there are but two 
Mongols in 300 inmates, all over eight years of age. I know two grow- 
ing children, distinct Mongols, who possess a fair degree of intelligence. 
Such instances, however, are very exceptional. Development is 
generally delayed, the teeth appear late, and what speech abihty is 
attained is aquired only after the child is four or five years of age. 

Diagnosis. — It is difficult to understand why so many of these cases 
fail of diagnosis. The patients are not at all Hke normal children and 




Fig. 67. — Mongolian idiot. 



may only be confused with cretins. (For differential diagnosis see 
Cretinism, p. 727.) 

Treatment of the Mentally Defective. — The mental defectives, with 
the exception of the cretin, the amaurotic family idiot and the spastic 
paralytic, lend themselves to one scheme or method of treatment, which 
is to be considered from two standpoints: first, that of attention 
to the physical condition ; secondly, that of attention to the mental con- 
dition. Under the first heading are included the correction of de- 
formities and the management as relates to hygiene and nutrition, both 
of which should be the best obtainable in any given case. The second 
consideration, relating to the mental aspect of the case, concerns not 
only the patient but the family and their immediate interests. 



506 



THE PRACTICE OF PEDIATRICS 



Institutions. — Almost without exception the place for a mentally 
defective child is in an institution which is devoted to the care and 
teaching of such children. The defective should be placed where much 
will not be expected, where he will be associated with others of his 
kind, where his work and his play will be adjusted and presided over by 
educated men and women who have made such conditions the study of 
their lives. The defective has his rights. He has a right to live out his 
unfortunate Hfe in as pleasant a manner as possible, and this is better 
accomplished in an institution than in any individual home. In an 
institution, among other things, such patients are taught, according 

to their capacity, useful 
occupations. Not a few 
thus taught become self- 
supporting. At rare in- 
tervals one is found who 
possesses remarkable 
mental traits along cer- 
tain lines, traits which 
the average normal in- 
dividual is incapable of 
understanding. I have 
one such case under my 
care. Patients showing 
a moderate degree of 
infirmity often become 
skilled in handicraft. 
They execute mechan- 
ically with surprising ac- 
curacy. There have 
been great geniuses of the past who in some respects were not con- 
sidered mentally normal by their contemporaries. It is impossible to 
form even a fair estimate as to how the mentally defective child 
will develop, with age, and suitable instruction from those who are 
best able to discover his possibilities. 

Placing these children in public institutions is often strenuously 
objected to on sentimental grounds by the poorer members of society 
because of their fears and prejudices against such institutions. In 
consequence, many a child is kept at home, greatly to his detriment and 
to the decided injury of other children in the family. Time and again 
I have pleaded with the mothers and fathers of such children without 
avail. Few villages throughout the country do not have an idiot or an 
idiotic epileptic for school-boys to taunt and for school-girls to fear. 
Most pitiable objects are these human derelicts, with whom the State 
does not interfere because they are " harmless. '^ Sooner or later, if he 
lives, the idiot of poor parentage will become a public charge, and the 
better his condition at the time, the happier he will be. 

Parents of means and intelhgence will usually place such a child in 
one of the many private institutions that are conducted for the care of 




Fig. 68. — Mongolian idiot, showing advanced 
malnutrition (five months). 



AMAUROTIC FAMILY IDIOCY 507 

defectives; but the objection will often be raised, even by these parents, 
that such children have so little mentality that teaching is useless. 
This may be true, but on this very account, if for no other reason, the 
child should be removed from the home because of his invariably per- 
nicious influence on other members of the family. 

The vicious, the unclean, and those showing marked moral degen- 
eracy should be placed in institutions as soon after the fourth year as 
possible. If they are to be a public charge, they should be removed 
from the home as soon as they arrive at the age limit which the rules 
of the institution require for admission. A patient who is tractable 
may remain at home until the sixth or seventh year, particularly if there 
are no other children in the family. If there are in the family younger 
children, whose natural tendencies and powers of imitation are always 
strong, the defective child should be removed as early as possible. 

AMAUROTIC FAMILY IDIOCY 

Amaurotic family idiocy is the name given by Sachs,* of New York, 
to a very peculiar disease of infancy, first described by Warren Tay 
in 1881. It is characterized by an impairment of the muscle functions, 
volitional movements being at first difficult and later impossible, the 
changes being of a progressive type. Defective vision and mental 
dulness appearing in a normal child are among the early signs. The 
disease progresses to complete idiocy and blindness. (See Figs. 69 
and 70.) 

Etiology. — The etiology of this form of idiocy is unknown. It oc- 
curs with considerable regularity in Hebrews. Different children in 
the same family may be affected. The disease, together with many 
others whose origin is not understood, has been attributed to syphilis 
and alcohol. The pathologic findings prove the disease to be due to a 
toxemia which slowly but persistently attacks and entirely destroys, 
through degenerative processes, whatever is vital in the entire nervous 
system. 

Pathology. — Consistence is again shown in the lesions of the disease, 
which, wherever present, are invariably the same. 

Hirsch's early findings have been corroborated by many others, 
showing that there is a degeneration of the ganglion cells throughout 
the entire nervous system. If we are to believe these investigations, 
there is not- a normal cell left either in the cortex or the gray matter of 
the cord. 

The cell protoplasm undergoes degeneration, the nucleus is demon- 
strable with difficulty and becomes a part of the degenerated cell. 
Later changes cause an entire loss of cell structure and render it diffi- 
cult to determine the cell contour. 

The ganglion-cells of the retina and the fibers of the optic nerves 
and tracts are degenerated, this fact accounting* for the blindness. 
Degeneration of the white fibers of the anterior and lateral pyramidal 
* Sachs' Nervous Disorders of Children, p. 462. 



508 



THE PRACTICE OF PEDIATRICS 



tracts has been described by Shaffer. Sachs is of the opinion that these 
are secondary changes. 

The thoracic and abdominal viscera show no specific lesions. 

Symptoms. — The history is usually that of a child born well and 
who remained in a normal condition until he was five or six, or perhaps 
nine, months old. He then became inactive, listless, and failed to 





Fig. 69. — Amaurotic idiocy. (Early stage.) 

follow objects or persons with the eyes. In all probability the sight is 
impaired much earher than is supposed, as in the four cases which I 
have had the opportunity to examine blindness was present early in 
the disease. A marked degree of visual impairment as well as men- 
tal apathy will pass unobserved in many of the homes of the class 
who supply the amaurotic idiot. The eyes assume a peculiar fixed 





««i,_ 



Fig. 70. — Amaurotic idiocy. Same case, (Late stage.) 

stare fairly early in the disease, not unlike that of the later stage 
of meningitis. The child not only shows apathy and indifference, but 
is soon unable to sit up or support the head, which falls in any direc- 
tion in response to the force of gravity. As the case progresses the 
patient loses all power — even the power of changing the position of a 
limb. With the mental, visual, and muscle impairment, there is in- 



HYDROCEPHALUS 509 

variably progressive emaciation. Convulsions and nystagmus may be 
present but are not characteristic symptoms. 

Fairly early in the disease there is an unusual susceptibility to sound ; 
clapping the hands or any inconsiderable noise causes the child to start 
violently. The reflexes vary at different periods and are variable and 
unreliable. Toward the end the respiration becomes very superficial, 
swallowing is impossible, and the child must be fed by gavage. When 
death occurs, the child presents the picture of marked inanition. 

Course and Prognosis. — The onset of the disease is very gradual. 
Its course is slow, with the evidence of progressive degeneration. The 
outcome is invariably fatal. A not uninteresting feature of the cases 
is their similarity. They occur in the same race of people. The onset, 
course, and termination are alike, even to the time required for the dis- 
ease to run its course. There is almost a mathematical succession of 
events. 

Diagnosis. — The disease is sometimes mistaken for meningitis. 
Other cases have been mistaken for those of birth-palsy. Even if there 
should be occasion for confusion because of the similarity of symptoms, 
which is very slight, the examination of the eye-grounds, which should 
be undertaken in every case in which there is a suspicion of cerebral in- 
volvement, renders the differentiation possible through the presence or 
absence of *' symmetric changes in the region of the yellow spot in each 
eye of an infant " (Tay) . This lesion Tay and Kingdon have designated 
as the ''cherry red spot." The presence of this sign makes the 
diagnosis in a suspected case positive, proving the presence of optic 
nerve atrophy. 

Treatment. — Treatment is of no avail. Our best efforts for these 
patients are to be exerted in maintaining nutrition and in ministering 
to their comfort. 

HYDROCEPHALUS 

By hydrocephalus is understood an excessive amount of fluid within 
the skull. This fluid may be either within the brain, in the ventricles 
(internal hydrocephalus), or it may be external to the lesion, existing 
as an effusion into the subarachnoid space (external hydrocephalus). 
Further differentiation is made into the acute and chronic, congenital 
and acquired, types. A fault in our nomenclature is that there is too 
much of it. It is a question whether a differentiation into the acute and 
acquired types is possible, for no one can state that in the cases which 
develop late — the so-called acquired cases — there was not an excessive 
effusion at birth. In fact, acquired internal hydrocephalus is an ex- 
ceedingly rare condition. When it occurs, it is usually the result of 
some mechanical venous obstruction. It is very common in cases 
of meningitis, due to inflammatory material closing the foramen of 
Magendie. The aqueduct of Sylvius may also be occluded. 

Sachs* states that the most common form of obstruction is that due 
to tumor in the posterior fossa. Through such obstruction the foramen 
* Nervous Diseases of Children. 



510 THE PRACTICE OF PEDIATRICS 

of Magendie may become occluded, and dilatation of the third ventricle 
result. Inflammatory processes may cause a closure of the communi- 
cating channels between the ventricles and cause a hydrocephalus. 
The amount of fluid in the acquired cases is usually small. 

Congenital Hydrocephalus, — I have seen a large number of these 
cases, and have made frequent autopsies upon hydrocephalus subjects. 
An excessive accumulation of fluid develops in the cranial cavities during 
intra-uterine life, which has been attributed to many causes, among 
which syphilis and alcoholism are frequently mentioned. My own ex- 
perience is in accord with that of many other observers, in that no 
satisfactory explanation for the condition has been found. 

Congenital hydrocephalus is essentially chronic. It is an internal 
hydrocephalus, that form of the disease which is usually seen, and the 
condition referred to when the term hydrocephalus is used without 
qualification. The head may reach an enormous size. Holt reports 
a case in which five pints of fluids were found at the autopsy. In one 
case seen by me there were three pints; the usual amount is from one- 
half to two pints. 

The fluid is clear, and contains the chlorid of potassium and soda, 
cholesterin, a trace of albumin, and sometimes urea. As a result of 
the pressure exerted, the brain substance becomes thinned to a mere 
shell. The convolutions are entirely obliterated. Removal intact of 
what is left of the brain may be impossible after the withdrawal of the 
fluid, owing to the fact that what remains of the brain tissue falls 
together in a broken mass. 

The ependyma may be normal or thickened and infiltrated. 

Chronic external hydrocephalus is of rare occurrence. When present 
it will be found associated in nearly all cases with a pachymeningitis. 
The congenital form of external hydrocephalus is exceedingly rare. 
Very few authentic cases have been reported. 

Internal hydrocephalus (acute) is of infectious origin. Any of the 
pathogenic bacteria may be operative, and the symptoms that are 
presented are those of pressure, seen in the various forms of meningitis. 

Symptoms. — In a case of the usual type, — the congenital, — which 
develops into chronic hydrocephalus, it is noticed at birth that the 
child's head is large. During the following week it is apparent that 
the head is increasing out of proportion to the remainder of the 
body. The skull enlarges symmetrically out of proportion to the face 
(Fig. 71). There are bulging of the fontanel and separation of the 
sutures. The blue veins of the scalp become enlarged and promi- 
nently outlined in the pale skin. The head may reach an enormous 
size. In one of my cases the circumference was 28 inches at the time 
of death — the ninth month. The infant in advanced cases is not able 
to hold up the head. He is dull and stupid, cries when disturbed, and 
takes food often with indifference. The facial aspect is characteristic 
— triangular, pinched, and pale. The eyes take on a peculiar stare 
and are directed downward, showing considerable paling of the sclera 
above, and never below. There is usually convergent strabismus, and 



HYDROCEPHALUS 



511 



there may be nystagmus. I have observed the latter in quite a number 
of cases. 

Malnutrition is always present. Dentition is delayed. The hair 
is scanty and coarse. Resistance is of a very low order. 

Nervous manifestations, relating to the extremities, are not neces- 
sarily present. I have repeatedly been surprised to note this feature 
of the disease. Some patients will show a moderate degree of spastic 
muscular contraction. The hands may be clinched and the feet ex- 
tended. In others no nervous manifestations whatever will be referable 
to the extremities. 




Fig. 71. — Internal chronic hydrocephalus. 

Duration. — The child rarely lives to the twelfth month. Intercur- 
rent disease, usually a bronchopneumonia or an intestinal infection, 
terminates the case. 

The above is a description of hydrocephalus as usually encountered. 
The course and outcome, however, are not always the same. The proc- 
ess may be arrested at any time. I have seen a few such cases. The 
enlargement of the cranium in these patients is slower, and noticeable 
enlargement may not occur until the fifth or sixth month is reached. 

Illustrative Cases. — A private female patient had suffered from digestive dis- 
turbance and moderate malnutrition in the early months. She improved satis- 
factorily, so that an interval of six weeks elapsed without my seeing her. When 



512 THE PRACTICE OF PEDIATRICS 

she was five months old I had occasion to readjust her food, and was astounded to 
note the change in the size of the child's head. It showed the characteristic 
globular form, the high forehead, and large fontanel, but there was no separation 
of the sutures. The circumference was 17 inches. Squint or nystagmus was not 
present, and the child supported the head well. During the next two months the 
head increased in size three inches. It remained at 20 inches for four months. 
The child is now six years of age and is normal in all respects. 

Another female patient first came when she was one year old. The mother 
thought that the head had been growing out of proportion to the body for a few 
months. The growth continued until the child was two years old, at which time 
the circumference of the head was 22 inches. The patient was last seen when six 
years of age. The mother considered the child mentally normal, although we were 
not convinced that such was the case. 

Cases such as the foregoing are those which are reported as cured 
from time to time by various methods of treatment. Further, they 
might be looked upon as belonging to the so-called acquired type. 
Such cases demonstrate that there may be a hydrocephalic process 
quite active in character which subsides of its own accord, as no treat- 
ment was given these patients except proper food and suitable general 
care. 

Many authors maintain that cured hydrocephalus is not at all un- 
usual. Sachs states that the protruding occipital bone, clearly visible 
on so many bald heads, points to a moderate amount of internal hy- 
drocephalus in the early years of life. 

Prognosis. — The prognosis is decidedly unfavorable in those cases 
in which the hydrocephalus is present at birth. Practically all such 
patients die before the tenth month. Occasionally one will live to be 
over one year old. In the Cases of slower or possibly later development 
there is a possibility of spontaneous cure. 

Diagnosis. — The diagnosis is not difficult. There is an enlarge- 
ment of the cranium, which is fairly evenly distended in all directions. 
The fontanel is enlarged and pulsating, and the sutures are widened. 

The rachitic and the hydrocephalic head are frequently confused. 
In hydrocephalus the veins of the scalp are distended, and nystagmus 
and squint are present. Early in the case, if doubt is felt as to the 
nature of the trouble, weekly measurements of the skull will determine 
whether or not there is an excessive growth. 

At birth the head of the average male is 14 inches in circumference ; 
that of the female, 13^ inches. At one year the cranium has increased 
to 18 inches in boys and to 17^ inches in girls. 

At the age of two years the head of the average male measures 19 
inches, and that of the female, 18J^ inches. 

Treatment. — No treatment at the present time will cure hydrocepha- 
lus. The cases that recover may have been influenced by suitable 
feeding and unusual cure ; and drugs which may have the effect of pro- 
ducing a better body upbuilding may have some influence on the dis- 
ease, but of this we are not positive. Many measures of many kinds — 
medical, dietetic, manipulation, and operative — have been attempted 
by hundreds of physicians. 

lodid of potash and mercury have been extensively used. Hydro- 
cephalic heads have been bound in elastic, which compressed the brain 



CEREBRAL PALSIES 513 

tissue all the more. The ventricles of the brain and the cerebrospinal 
canal have been tapped and drained by various methods. 

No operative procedure up to the present time has proved of any 
permanent value. 

CEREBRAL PALSIES 

Three forms of this affection are recognized — the prenatal, the hirth, 
and the postnatal or acquired palsies. 

The Prenatal and Birth Forms 

Etiology. — Concerning the etiology of the prenatal cases, consider- 
able confusion and varying opinions exist. Degeneracy of the parents, 
alcoholism, syphilis, and trauma are supposed to be contributory 
causes. I have seen a large number of undoubted prenatal cases, and 
am unable to add anything from the etiologic standpoint. In several 
instances the patients have belonged to families in which there were 
several other children, all normal, with nothing worthy of note in the 
family history, and a record of a normal, uneventful pregnancy pre- 
ceding the birth of the patient. 

Trauma at birth, whether due to the use of forceps or to compres- 
sion of the head in a prolonged or abnormal delivery, may result in 
meningeal hemorrhages, causing cerebral palsy. An immense number 
of cases are thus caused. The obstetrician should always keep in mind 
that with him rests the possibility of making a hopeless invalid or an 
idiot of the child he is about to deliver. It is fully appreciated that 
under unusual conditions in obstetric practice certain risks of head 
injury must be taken for the sake of the immediate demands of the 
mother or the child, but the large number of cases of cerebral palsy 
and idiocy which I have seen have impressed upon me the necessity 
of treating the child's head during delivery with the utmost care. 

Lesions. — The prenatal and birth palsies are often paraplegias or 
diplegias, and as such show a great variety of lesions. 

In the prenatal cases there is often failure of development of a por- 
tion of, or an entire hemisphere. Cysts are sometimes found at au- 
topsy. In other cases there will be no visible change to the naked eye. 
Microscopic examination of the brain tissue shows a lack of develop- 
ment of the cells in the motor areas. In the cases due to trauma at 
birth the results of the early hemorrhage will be found. The most usual 
changes are sclerosis and atrophy. 

In general, the lesions of cerebral palsy include meningeal and 
cerebral hemorrhages, thrombosis and embolism, meningitis and 
encephalitis, direct injury, tumors, atrophy, sclerosis, and cyst forma- 
tion. 

Atrophy, sclerosis, and cysts are the conditions most frequently 
observed at autopsies. Such changes are apparently secondary, and 
may generally be ascribed to previous embolism, thrombosis, hemor- 
rhage, or encephalitis. 

Meningeal hemorrhage is much more common than hemorrhage 
33 



514 THE PKACTICE OF PEDIATRICS 

from a cerebral vessel. Endarteritis and pachymeningitis are predis- 
posing causes, and direct trauma and the local congestion incident to 
convulsions or spasms of coughing are exciting causes of such hemor- 
rhage. 

Thrombosis and embolism are rare in children, but may occur. 
Thrombosis is sometimes found in cases of marasmus, and in other 
instances may be ascribed to syphilitic endarteritis. Emboli are, as a 
rule, of cardiac origin, and lodge in a branch of the middle cerebral 
artery. Embolism may occur in the course of acute infectious fevers. 

Encephalitis may result from an acute infection or from trauma. 
Acute polio-encephalitis as a cause of palsy, is well recognized. Ac- 
cording to Cautley, three-fourths of the cases of acquired cerebral 
paralysis in children develop before the fourth year. 

Sachs states that, prior to autopsy in a case of acute cerebral palsy 
of several years' duration, it is impossible to predict what type of 
secondary brain lesion will be found. When the symptoms have been 
well defined and focal, and associated with little idiocy, he has in sev- 
eral instances correctly diagnosed the presence of cysts. Idiocy and 
epilepsy, associated with cerebral palsy, are symptoms which he attri- 
butes chiefly to sclerosis. 

Symptoms. — Hemiplegia is rare except in the acquired cases. In 
the prenatal cases, and those due to injury at birth, which latter con- 
stitute by far the majority, there is frequently a diplegia or paraplegia. 
The first symptom of trouble in these cases is usually that of spasticity 
or rigidity of the extremities, with a decided restriction in motion. 
There may be rigidity of the neck muscles. The children are often 
''head-borers." 

One extremity may show much more involvement than the other. 
Spasticity and lead-pipe rigidity characterize the condition of the 
muscles. The reflexes are usually exaggerated. Owing to the per- 
sistent spasticity, the patient may be unable to walk or use the hands. 
If walking is accomplished, it is learned much later than is normal. 
Often walking is interfered with because of spasm of the adductors, 
which produces a cross-legged attitude. In those cases in which walk- 
ing is- finally accomplished, the patient is very awkward and falls fre- 
quently. In a State institution for defectives which I recently visited, 
70 out of 300 inmates, ranging from eight years to over forty, had never 
walked. 

The physical development is always of an inferior order in cases 
even moderately severe. The ability to hold the head erect is ac- 
complished very late. I have repeatedly had patients who could not 
support the head at the fourth or fifth year. Deafness and blindness 
are not at all unusual. Nystagmus and strabismus are frequently 
seen. Speech is apt to be acquired late and may be very defective. 
The ability to swallow solid food is often very much delayed. Even 
the swallowing of fluid can be accomplished only in a certain position. 
A child of whom I had charge for several years could swallow fluids 
only when resting on his back. The impairment continued during the 



CEREBRAL PALSIES 515 

six years of life of the child. The physical impairment varies widely 
in degree from what appears as simple awkwardness to complete inability 
to perform a single volitional act. The legs usually show much greater 
involvement than the arms. A child who has little or no use of the legs 
may be able to use the arms to good effect. 

Fortunately, many of these unfortunates die during the earlier 
years. Their resistance to infection is of a low order. Convulsions may 
occur, but have not been of frequent occurrence in my own cases. 

Mentality. — The mental capacity is also of wide variation. I have* 
under my care at the time of writing four patients with normal men- 
tality. Two, through gymnastic exercises and training, are able to 
perform all volitional acts and are looked upon as normal children. 
There is still a slight impairment in gait, and they are known among 
their fellows as " clumsy " boys. The other two, girls, possess unusually 
bright minds, but are pronounced diplegics. One is fourteen years 
of age and has never walked without support, the other is six years 
of age. She is now walking alone but with much difficulty. The 
gait is still decidedly spastic. She has had daily treatment since 
two years of age. The latter will probably walk in a year or two. 
On the other hand I see several patients every year whose mentality 
is of a very low order. 

Between these two extremes there are all degrees of mental impair- 
ment. Not infrequently these defective children possess decided 
brilliancy along a certain line, while the mind is a complete blank 
in other respects. Defectives often learn to accomplish purely mechan- 
ical acts very well indeed. They may become intense specialists. 
A defective boy has developed into an expert carver of wood. I have 
known two very clever musicians who were defective in every other 
respect. 

Epilepsy. — Authors claim that epilepsy is present in a considerable 
proportion of defectives. Such has not been my experience. In fact, 
in a large experience with, children of this type epilepsy has been very 
exceptional. 

The Acquired Form 

Hemiplegia may be said to characterize the acquired cases, and while 
diplegia and paraplegia may occur, this is the exception. 

Etiology. — My cases have all been the result of infection, stress, 
or direct trauma. A comparatively trifling injury is sometimes suffi- 
cient to produce a hemorrhage. 

Illustrative Cases. — A boy twelve years of age, a pronounced hemiplegia with, 
normal mentality, owes his present condition to a fall from his baby-carriage to the 
ground when nine months of age. The fall was followed by repeated convulsions 
and hemiplegia. He came under my care a few days after the fall. The clot was 
located, the skull trephined, the blood-clot removed, and the bleeding vessel 
ligated. The boy today walks well with a brace; the arm will probably never 
be of much service. 

Another child, fourteen months of age, was perfectly normal previous to an 
acute attack of indigestion with high fever and convulsions. The seizures were 
repeated several times during the day. After the third convulsion it was noticed 



516 THE PRACTICE OF PEDIATRICS 

that there was complete paralysis of the left side of the face and of the right arm 
and leg. The child died thirteen months afterward. His mentality was never 
clear. 

A mother and her seven-months'-old babe went in bathing at the seashore, 
the babe in the mother's arms. A ground swell engulfed them. When the child 
was resuscitated, it was found that there was complete hemiplegia. 

My most recent case occurred during pertussis. Hemiplegia developed after 
a severe paroxysm. The child lost consciousness, which was not regained; and 
death followed in seventy hours as a result of cerebral hemorrhage. 

A child eleven months of age fell to the floor from his crib striking on the head. 
Hemiplegia developed at once, followed by death in a few hours. Autopsy showed 
extensive cerebral hemorrhage. 

Hemiplegia may be the result of congenital syphilis. I have seen 
such cases. The Wasserman test should always be taken in every 
child in whom hemiplegia develops. In hemiplegia with congenital 
syphilis there is usually no prodromal symptom. The paralysis is 
noticed when the child wakes in the moi^ning or develops spontane- 
ously during the day. 

Any of the diseases of bacterial origin may cause cerebral palsy of 
the hemiplegic type. Infection as a cause, however, is very infrequent. 
(This opinion is based entirely on my own experience.) More cases 
probably result from cerebrospinal meningitis than from any other 
form of infection. The lesions in the cases reported as occurring with 
various infectious diseases and gastro-enteric disturbances are prob- 
ably the result of the convulsions which may have ushered in the 
illness. 

A convulsion is never without danger in a child. 

Age. — It is unusual for a case to develop after the seventh year. 
The majority of the cases occur before the fourth year. 

Symptoms. — The first symptom is usually that of paralysis follow- 
ing a convulsion or trauma. In some cases there is paralysis (hemi- 
plegia) only; in others, profound mental disturbance. The duration 
of the paralysis depends upon the nature and extent of the injury. 
The paralysis, which is spastic in character, may completely disappear, 
or permanent disability with contractures may remain. Usually there 
is some impairment of power. The arm functions may be com- 
pletely restored. The leg improves less rapidly, and is more apt to 
show permanent disability. (This is the reverse of the experience of 
most authors.) Not infrequently the patient develops one of the 
various forms of club-foot, which means that certain muscle groups 
have been particularly involved. 

The facial muscles are involved in a small proportion of the cases — 
perhaps 15 per cent. Complete restoration to the normal is the rule. 
The patellar reflex is usually exaggerated on both sides, but most 
markedly in the leg of the affected side. The gait may be interfered 
with, or the function of the limb may be entirely lost. In other cases 
in which the focal lesion is less pronounced, walking may be accom- 
plished after orthopedic attention. 

Electric Reaction. — The reaction of degeneration is usually present. 

Sensation is not permanently disturbed. Early in some cases there 



CEREBRAL PALSIES 517 

appears to be some impairment ; this, owing to the mental state of the 
patient, may be difficult to determine accurately. 

Disturbance of Speech. — Aphasia is present when there is a left 
third frontal lobe involvement. Impairment of speech may also occur 
when the right hemisphere is affected, although to a lesser degree. 
When the speech center in the left hemisphere is involved, the right 
may take on the function. 

Incoordinate Movements. — Incoordination of the paralyzed parts, 
particularly of the arm, has been repeatedly observed. These non- 
voHtional movements have been erroneously termed "choreic." 

Illustrative Case. — A patient two years of age had, at the age of one year, 
repeated and prolonged convulsions covering a period of three days. Pronounced 
hemiplegia resulted, with mental impairment. After one year the hemiplegia 
entirely disappeared, but phenomena of muscle gymnastics remain that are 
difficult to describe. The child rocks and sways the body. The muscles of the 
right side of the face undergo frequent rapid contractions and relaxations. Volun- 
tary muscular acts are readily accomplished. Athetosis is present in a marked 
degree. There are rhythmic motions of the flexors and extensors of the fingers, and 
flexors and extensors of the forearm. The child's mentality is still much impaired. 

Athetosis is of more usual occurrence in cases in which the lesion 
has apparently been severe. 

Epilepsy may be expected in any case of hemiplegia. Gowers 
states that it occurred in over 60 per cent, of his cases. Sachs reported 
epilepsy in 50 per cent. Epilepsy may not occur until several years 
have elapsed. Thus, in a case of my own, the child had the injury 
and hemiplegia when nine months of age, and did not develop epilepsy 
until the tenth year. 

Epilepsy, when it develops, is usually of the Jacksonian type, and 
is often very mild in character. 

Mental Impairment. — While mental impairment may be said to be 
the rule, it by no means follows that a child with hemiplegia may 
not be perfectly normal mentally. It would naturally be supposed 
that involvement early in life would be particularly likely to affect the 
mentality, and such is the case. Nevertheless, I have seen patients 
with conditions of this nature make complete recovery and become 
mentally competent individuals. The intelligence may be normal, or 
there may be complete idiocy, or any degree of impairment between 
these extremes. 

Diagnosis. — The diagnosis is not difficult. In the prenatal and 
birth cases there are early diplegia and paraplegia, with unmistakable 
evidence of mental impairment. The child does not smile or hold up 
the head or attempt to play with toys at the usual age, and is slow to 
recognize people or surroundings. There may be difficulty in swallow- 
ing and inability to perform volitional acts. All these patients have a 
characteristic vacant expression — a meaningless stare. 

In the acquired cases the paralysis is unilateral, with exaggerated 
reflexes on the involved side. 

Further, there is usually the history of trauma and sudden onset. 

Treatment. — The medical treatment of the paralysis consists in 



518 THE PRACTICE OF PEDIATRICS 

maintaining a high degree of nutrition. The management, in general, 
in the different types of cases, varies, depending upon the intelhgence 
of the patient, the location and extent of the paralysis, and the resulting 
deformity. Braces are necessary in many instances to prevent con- 
tractures and deformities, as well as to aid in correcting those already 
present. In some of my cases of normal or fair mentality, marked im- 
provement has followed daily systematic manipulations and exercises 
(p. 830) under the management of an expert in this line of work. 

A description of operative measures and a discussion of the cases in 
which they are applicable may be found in all works on orthopedics. 
Systematic exercise, massage, and training in the use of the limbs 
constitute the latter management of all operative cases, in order that 
the patients may derive full benefit from the operation. 

CHOREA (ST. VITUS^ DANCE) 

Chorea, in the form originally described by Paracelsus, is extinct. 
In the Middle Ages, however, a form of dancing mania was widely epi- 
demic throughout Europe, and sketches will testify to enormous four- 
teenth century pilgrimages to the shrine of St. Vitus. The term chorea 
ordinarily applies to the condition described by Sydenham, in 1686; 
and the names chorea minor, chorea vulgaris,. and chorea anglorum are 
synonymous. 

Under the general title, furthermore, are grouped such cases as 
those described by Huntington in 1872 as hereditary in type, and a 
large heterogenous collection designated by such self-explanatory terms 
as chronic 'progressive chorea, chronic adult chorea, congenital chorea, 
senile chorea, chorea gravidarum, posthemiplegic chorea, choreic insanity, 
and electric chorea or Dubinins disease (which is marked by the sudden 
character of the spasms). Chorea major is a variety of hysteria. 

Incoordination characterizes chorea in children. The child's 
control over the muscle movement is partially or entirely lost. In 
addition, there are involuntary muscle movements and twitchings, and 
there is loss of muscle power. 

Etiology. — The disease occurs more frequently in girls than in boys 
The proportion in my own cases is two to one. 

The susceptible age is from the sixth to the tenth year. The age 
range in my own cases has been from four to sixteen years. These ob- 
servations are in accord with those of other writers. 

Fright as a factor in causing chorea has been greatly overestimated. 
In a susceptible child the occurrence of stress of any nature may in- 
duce an attack. Regardless of the nervous shock, there is no chorea 
without the underlying constitutional vice. Overwork at school is to 
be looked upon as a predisposing cause, as also is anemia or any 
influence affecting the well-being of the child. But such conditions 
are operative only in favorable subjects. 

Basing my judgment on a large number of cases both in private and 
out-patient work, I agree with the accepted opinion of most writers 
that rheumatism takes a first place in the etiology of this disease. 



CHOREA (ST. VITUS' DANCE) 519 

Strtimpell several years ago wrote that the association of chorea and 
rheumatism is so close that it is impossible to separate them. Hirt, 
in discussing nervous diseases, expressed the view that there is a com- 
mon toxic etiologic factor which, affecting the cortex, produces chorea, 
but affecting the joints gives rise to acute articular rheumatism. The 
association of rheumatism and chorea is certainly most intimate. A 
trifle over 50 per cent, of my cases either gave a history of rheumatic 
manifestations, or showed evidence of rheumatism, when first seen, or 
developed the signs later. 

If to the above are added the cases of chorea in which there is a 
family history of some form of rheumatism, the percentage is increased 
to over 80 per cent. The association so generally observed clinically 
is further borne out by the results of treatment. 

Pathology. — Much has been written concerning the pathology, and 
widely diverse opinions are held. The fact that the child makes a 
complete recovery in a few weeks, and that no permanent lesion is 
demonstrable after several acute attacks, proves that there is no grave 
lesion. A systemic toxemia affecting the centers in the cortex is un- 
questionably present. 

Poynton and Paine have found the diplococcus of rheumatism in 
films made from the pia mater in a fatal case of chorea. The cocci 
were seen in the vicinity of a blood-vessel. Poynton* gives a cut 
showing this condition, but no further details. Morse and Floyd 
found cocci in the blood in four out of 31 chorea cases studied but 
their work proved nothing definite. 

The spinal fluid in chorea is clear. In about 30 per cent, of cases 
Morse and Floyd found a very slight increase in the number of cells, 
all of which were mononuclear in type. No micro-organisms are 
present. 

Symptoms, — The onset of symptoms is most variable. Usually the 
child will show apparent awkwardness in using one of the hands, or will 
stumble in walking or will exhibit a hesitancy in speech which is un- 
usual. Such symptoms will be present for a week or more and the 
child will usually be reproved for his awkwardness in handhng his 
drinking glass, knife or fork. The condition may go no further than 
this, or, as is usually the case, the nervous manifestations continue. 
The arms, hands, and fingers may twitch and show short clonic con- 
tractions of certain muscles. At the commencement one arm is 
usually involved more than the other. This tendency to lateral in- 
volvement may continue throughout the attack. The order of in- 
volvement is usually the right arm, left arm, right leg, and left leg. 
The limb involved is much weaker than its fellow. This, in the ex- 
aminations of the upper extremities, may be readily appreciated by 
asking the patient to squeeze the examiner's hand, the patient using 
first one hand and then the other. 

The muscles of the face or of the shoulders, in fact, those of any por- 
tion of the body, may be prominently involved, but this is unusual. 
* "The British Journal of Children's Diseases," 1912, vol. ix, p. 49. 



520 THE PRACTICE OF PEDIATRICS 

In association with the involuntary muscular contractions, there is 
lack of coordinatioUj a further development of the awkwardness seen 
early in the attack. The movement of the hand, for example, is slow 
or absolutely refuses to obey the will, and the movement is only ac- 
complished after pronounced effort or not at all. Thus when a choreic 
patient is told to place the tip of one index-finger on the tip of the nose 
or the tip of each index-finger alternately on the tip of the nose in re- 
peated succession, returning the arms in an extended position to his 
sides, the child experiences much confusion, and the fingers rarely reach 
the tip of the nose. Another test is to extend the arms in an outward 
direction and then bring the tips of the index-fingers together quickly. 
The choreic patient will experience much difficulty in its accomplish- 
ment. I have had eight patients under ten years of age who were con- 
fined to their beds and who could perform no voluntary act. Self- 
feeding was out of the question ; and walking, an impossibility. 

Muscle instability may be further demonstrated by the inability 
of the patient to maintain muscle tension. Thus, wrinkling the brows 
or holding the eyes tightly shut can be continued but a few seconds. 
When the child is asked to protrude the tongue and keep it protruded, 
the organ may undergo various contractions until it is under control, 
and even when at rest will show fine fibrillary twitchings. The facial 
muscles offer a large field for muscle gymnastics with grotesque effects. 
All or any of the voluntary muscles may be involved. There is inco- 
ordination, and lack of power and muscle control. 

Diagnosis. — The diagnosis is made on the presence of muscle con- 
tractions beyond the control of the will, resulting in awkwardness, 
grimaces, and inability to effect voluntary effort. Chorea is to .be 
differentiated from habit spasm — so-called "habit chorea" — by the 
fact that, in the latter, while there are contractions of various sets of 
muscles in the body, such contractions may be controlled by mental 
concentration, whereas in true chorea the attempt at control exagger- 
ates the incoordination. 

Prognosis. — The prognosis is good. I have seen a large number of 
cases and have never known one that did not recover if the patient was 
free from cardiac involvement. I have seen fatal cases of pancarditis 
(endocarditis, myocarditis, and pericarditis) in which chorea was one of 
the symptoms of the rheumatic infection, but in every case it was the 
heart involvement that killed the patient. 

Recurrence. — As with other rheumatic manifestations in children, 
there is with chorea a marked tendency toward a return. In its causa- 
tion there is, moreover, a seasonal element. The majority of the cases 
occur in the spring months of April and May. It has not been my ob- 
servation that the fall of the year is a predisposing factor. Repeatedly 
in out-patient work where continuous supervision is impossible I have 
seen these choreic children return year after year for treatment. We 
get acquainted with the children and look for their return. 

Duration. — The duration of these cases depends upon the nervous 
organization of the child, the severity of the attack, and the cooperation 



CHOREA (ST. VITUS' DANCE) 521 

to be gained from the patient's family. I have had fairly severe cases 
recover in six weeks, and others that required six months of treatment. 

Treatment. — Rest Treatment. — The management of chorea depends 
entirely upon the degree of severity of the attack. It may be neces- 
sary in extreme cases to keep the child in bed from three to four weeks. 
In other cases, in which the attack is milder in character, the enforced 
rest may do harm. Formerly I treated more cases on the plan of ex- 
treme rest than I do at present. When the involuntary movements 
are so marked as to interfere with locomotion and prevent the child's 
feeding himself, rest in bed for a week or two is strongly advised. In 
my observation it is mental repose that the patients particularly re- 
quire, and if this can best be obtained in bed, then the bed is the best 
place for the patient. If an absence of mental excitement and stimu- 
lation can be secured, with a reasonable amount of outdoor life and 
exercise, so much the better. An important fact to be remembered in 
the management of choreic children is that they must not be allowed 
to become fatigued either physically or mentally. 

For the patient who has been confined to bed for several days 
or weeks, a gradual return to the usual habits is best. The child should 
be taken up for one-half hour the first day, increasing the time out of 
bed one-half hour daily, until he returns to his usual habits of life. 

School and Entertainment. — Specific instructions as to the amount 
of physical and mental rest required cannot be given so as to apply 
generally in the management of chorea. School and entertainments 
for the choreic patient are, however, out of the question, no matter 
how mild the case. In the great majority of cases play with other 
children must be prohibited. Books and play of an exciting nature 
are to be particularly avoided. The physician shouM especially re- 
member that there must be no bodily fatigue and no mental stimula- 
tion of any nature whatever. How best to bring this about will depend 
upon the child and his environment. 

In two instances I have been obliged to remove the patient from his 
home to a place among other relatives. The influence of the mother 
was such as hopelessly to prevent the child's recovery. In a recent 
severe case of a boy of twelve years, a college student was selected to 
turn the patient's attention to boyish things, games, target practice, 
horseback riding, etc. The boy was kept in bed until 9 a. m., rested 
two hours after the midday meal, and retired at 7 p. m. He was prac- 
tically well in four weeks. 

Antirheumatic Treatment. — By treating every case of chorea as 
though the disease were rheumatism, my results have been strikingly 
good. Not only is the child given the salicylates, but he is put on an 
antirheumatic diet. The tonsils should receive careful attention, and 
in repeated attacks enucleation should be practised. 

Drugs. — The salicylate of soda (true) may be given in smaller doses 
than are used in acute articular rheumatism — about 5 grains three 
times daily, with an equal amount of the bicarbonate of soda, being 
suitable for a child from six to ten years of age. The soda should be 



522 THE PRACTICE OF PEDIATRICS 

given between meals. To children of this age the salicylate may be 
given either in capsule or in solution. In the treatment of young chil- 
dren, the drugs in solution are more easily administered. During the 
past year I have given aspirin to a few patients in whom the digestive 
functions were weak or who could not take the salicylate of soda. In 
using salicylate of soda or aspirin for a considerable time it is well to 
remember that they may interfere with the appetite and digestion, no 
matter how great the care exercised in their use. For this reason it 
is my custom to give them intermittently — five days of medication 
being followed by five days without medicine. 

In spite of the value of the antirheumatic treatment, this alone will 
not answer, as I have proved to my satisfaction in not a few cases. 
The administration of the arsenic and the salicylate and the dietetic 
regime are begun at the same time. The salicylate of soda is given at 
once at the commencement of the treatment in as full doses as we ex- 
pect to give. Arsenic is commenced in a small dose, which is gradually 
increased in order to establish a tolerance of the drug. Fowler's solu- 
tion of arsenic is usually employed. In order that no error be made 
in its administration, a table similar to the following is given to the 
mother or attendant. For a child six years of age, on the first day, 
two drops should be given after each meal, as indicated below. There- 
after, the dosage is increased by one drop every twenty-four hours, 
according to the following schedule: 

DOSAGE OF FOWLER'S SOLUTION FOR A CHILD SIX YEARS OLD 

1st day — morning, 2 drops. Noon, 2 drops. Night, 2 drops. 



2d 


<( 


<' 


2 


a 


11 


2 


(( 


ii 


3 


3d 


li 


\i 


2 


a 


a 


3 


ii 


11 


3 


4th 


a 


11 


3 


<( 


tc 


3 


li 


11 


3 



This rate of daily increase is continued up to the third week, after 
which time the dosage should range from 5 to 10 drops three times a 
day. For a child of eight to ten years of age the amount may be in- 
creased to 12 or 15 drops three times a day. I have found that by 
putting the patient on the antirheumatic treatment much less arsenic 
is required, and that the patient usually makes an earlier recovery. I 
have never been obliged to resort to the large dosage of 25 to 30 drops 
of Fowler's solution three times a day, as suggested by Seguin. It is 
exceedingly rare that more than 10 drops three times daily will be 
required in order to procure satisfactory results. I have never found 
it necessary to give more than 12-drop doses to girls of thirteen to six- 
teen years old. A very recent aggravated case in a girl fifteen years 
of age terminated in complete recovery in three weeks under the anti- 
rheumatic diet, the use of aspirin, 10 grains three times daily after 
meals, and Fowler's solution up to 12 drops after each meal. 

Children vary greatly as to their tolerance of arsenic. A boy seven 
years old could not take more than four drops of Fowler's solution 
three times a day. 

In giving arsenic, mothers should therefore be advised that in the 



CHOREA (ST. VITUS' DANCe) 523 

event of abdominal pain, diarrhea, coated tongue, foul breath, vomit- 
ing, or puffiness under the eyes, the drug is to be discontinued for at 
least two days. The minimum dose may then be resumed with the 
same gradual increase. 

With the improvement of the case the diet should be continued. 
The medication may gradually be reduced after all the symptoms have 
disappeared. It should be continued, however, in from one-third to 
one-half the quantity for three weeks after the disappearance of all 
nervous symptoms. 

Supplementary Treatment. — It should be remembered that children 
who have once had chorea are very susceptible to recurrent attacks. 
This is also the case with children who have had rheumatism. After 
one attack of chorea the danger of a recurrence should be explained 
to the mother, who should be asked to bring the child for examination 
at the first suggestion of involuntary muscular twitching. In addition 
to this, children who have had chorea, as well as those who have had 
rheumatism, should be allowed meat but once every second day, and 
in no case should an excessive use of sugar be permitted. Candy is 
usually to be forbidden. Believing that these cases are rheumatic in 
origin, when the attack is over I order that the child shall receive 10 
grains of bicarbonate of soda three times daily for five days out of 
«very fifteen. In this way, under a reasonably quiet home life, with 
no school contests for prizes, etc., a recurrence will almost invariably 
be prevented. 

Goodman reports 30 cases of chorea treated by the auto-serum 
method, which is carried out as follows: 

After having excluded tuberculosis and syphilis, we permit the 
child to lie in bed for three or four days or longer, without any medica- 
tion. We lihen withdraw from a vein 45 or 50 c.c. of blood, and rapidly 
>centrifugalize it. The serum is then pipetted off and kept on ice. 
A lumbar puncture is performed in the usual manner. The fluid is 
very slowly withdrawn, and about 20 c.c. of the fluid is collected. 
The .serum is then heated to body temperature, and very slowly in- 
jected into the spinal canal. Such an injection should take from ten 
to fifteen minutes, and usually 15 to 18 c.c. of the serum is used. The 
patient should retain the recumbent position for at least one hour 
after the injection. From one to four injections were given — the 
interval is not stated. 

Goodman summarizes as follows: Of the 30 cases, 18 were female 
and 12 were male. The youngest case injected was four years of age, 
the oldest, twenty-eight. 

Of the 30 cases injected, 18 were under ten years of age, 10 were 
from ten to fifteen years of age, 1 from fifteen to twenty years of age, 
and 1 from twenty to thirty years of age. 

Of the 30 cases treated, 14 received one injection, 8 received two 
injections, 5 received three injections, and 3 received four injections. 

Of those receiving one injection, 12 were cured and 2 markedly 
improved. 



524 THE PRACTICE OF PEDIATRICS 

Of those receiving two injections, 5 were cured and 3 markedly 
improved. 

Of those receiving three injections, 2 were cured and 1 markedly 
improved, 1 slightly improved, and 1 unimproved. 

Of those receiving four injections, 1 was cured, 1 markedly im- 
proved, and 1 unimproved. 

To explain our interpretation of the results, cured means absolute 
cessation of all twitchings within a week. Markedly improved, a 
cessation of all twitchings within two weeks. Slightly improved, 
when the twitching disappears at the end of the third week and 
unimpaired if the twitchings are still present during the fourth week. 
Two of the cases reported are relapses. One occurred after 9 months 
and the other after 11 months. 

HABIT SPASM (TIC)* 

By habit spasm is understood a semi-incoordinate movement of 
some portion of the body. The term ''semi-incoordinate" is used ad- 
visedly, because the spasm may be controlled when the child's atten- 
tion is directed to it, this being one of the distinguishing features which 
differentiates it from chorea, in which efforts at control make the spasm 
worse. The muscles involved in the spasm are usually those of the 
head, face, or arm. The nose may be drawn up, the chin down, or the 
head to either side. The muscular spasm is worse when the patient 
is tired, and occurs more frequently under excitement. While these 
children cannot be said to have chorea, there is nevertheless a close 
association between habit spasm and true chorea. Habit spasm is 
most frequently seen in those of rheumatic inheritance who have had 
previous attacks of chorea or rheumatism, or the respiratory mani- 
festations so frequently seen in children of the rheumatic type. 

Several of my patients developed habit spasm from association 
with children who had some special grimace or habit of muscle con- 
traction of their own. 

The cases are readily curable when taken early. In neglected chil^ 
dren the spasm may become fixed and continue during the life of the 
individual. Instances of this sort are often seen in adults. Bad sub- 
jects will transfer the spasm from one set of muscles to another. 

Illustrative Case. — A boy, twelve years old, came to me because of a peculiar 
explosive sound similar to that made by eructations of gas. The sound was pro- 
duced through some process of laryngeal gymnastics and was almost continuous 
when awake. 

Treatment. — The management is dietetic, hygienic, and medicinal. 

Diet. — I allow these patients a small portion of red meat once a 
day. Sugar is given in sufficient amount to make the food palatable. 
The vegetable and legume constituents in the diet are made prominent. 

* Dr. Edward Wheeler Scripture, in his treatment of tics, has his patients 
stand in front of a mirror and imitate the tic, thus converting it from an involuntary 
to a volitional one. By this means he shows surprising results, especially when the 
tic is of recent acquirement. 



STAMMERING 525 

The patient will usually be found to be poorly nourished and often 
suffering from a secondary anemia, so that a diet best calculated to 
improve his general condition should be insisted upon. This should 
contain milk, eggs, poultry, fish, red meat in small portion, high-pro- 
teid cereals, and the legumes. 

Bath. — A salt bath should be given at bedtime, and immediately 
after the bath goose oil, unsalted lard, or oHve oil should be rubbed 
into the skin. 

School Duties. — Temporary absence from school, or a lightening of 
school duties, and an outdoor life are essential in the successful man- 
agement of a case. The child should not be allowed to do anything 
of a strenuous nature. Hard play and any amusement of an exciting 
character should be forbidden. Fatigue must be avoided. Rest after 
the noon-day meal for an hour or two is strongly recommended. 

Medication. — The medicinal treatment suggested for chorea is also 
applicable here. If there is anemia, iron may be given, preferably in 
the form of the extractum ferri pomatum, 3^ grain three times a day. 
For those children who cannot take cream or butter, cod-liver oil in 
teaspoonful doses is a valuable addition to the treatment. The iron 
may be alternated with the cod-liver oil, each being given for five 
days. If there is a rheumatic history or inheritance, aspirin or salicy- 
late of soda — preferably aspirin — is to be given in capsule with the 
iron. The following is useful for a child five years of age: 

*E^ Liquoris potassii arsenitis. gtt. iij 

Ext. ferri pomati gr. ss 

Aspirini gr- iij 

M. Sig. — One dose; to be given in capsule after each meal. 

The use of arsenic, while of advantage, does not appear to be as 
valuable here as in chorea. 

Moral Treatment. — Habit spasm, for the reason that it is practically 
under the control of the will, should be strictly forbidden, rewards 
being given and punishments imposed, as seem to answer best. 

STAMMERING 

Stammering is an affection for the most part limited to self-con- 
scious and precocious children with indifferent nervous control. The 
defect is seldom of importance before the fifth year and then usually 
may be found to be due to imitation of other stammerers. About 35 
per cent, of the patients are said to have relatives similarly affected. 
Boys are more frequent victims than girls. Fright gives rise to the 
condition in many instances. Of the concrete causes the most im- 
portant are adenoid and tonsillar hypertrophy, high palatal arch, im- 
perfect epiglottis, and short frenum linguae. The respiratory muscles 
commonly do not coordinate properly with the speech muscles and 
thus the subject even when in the act of articulating may lack the 
necessary voice. In the most pronounced cases not only the Hps and 
tongue, but also the face and limbs participate in the loss of control 
so that the child's self-reliance becomes greatly weakened. 



526 THE PRACTICE OF PEDIATRICS 

Treatment. — All measures that conduce to stability of the nervous 
system are of value in the cure of stammering. Anatomical abnor- 
malities should be corrected and breathing exercises should be insti- 
tuted to encourage better poise and coordination. Hollander reports 
the best results gained from suggestion treatment intended to increase 
the patient's self-confidence and emphasize the importance of his ideas, 
rather than his manner of utterance. Syllabication is a practice of 
special value. 

In the large centers there are clinics for the treatment of speech 
defects and the results gained by specialists in this department amply 
justify the formation of more such classes under trained supervision. 

THE PROGRESSIVE MUSCULAR ATROPHIES 

The progressive muscular atrophies fall easily into two main groups, 
called the amyotrophies and the myopathies. In cases of the first class 
there are lesions in the spinal cord. In cases of the second group such 
changes are not found. 

Progressive Spinal Muscular Atrophy or Progressive Amyotrophy 

This disease has received many designations, including the follow- 
ing: Chronic anterior poliomyelitis, wasting palsy, Charcot's disease, 
Duchenne-Aran' s disease, and amyotrophic lateral sclerosis. 

Some justification for the existence of so many terms is found both 
in the variable pathologic conditions and also in the length of the 
period of painstaking research which has made possible our present 
knowledge of the disease. The conditions observed are, however, 
fundamentally similar and admit of a common classification. 

Etiology. — Progressive amyotrophy is uncommon in early child- 
hood, although V/erdnig and Hoffmann have recognized a hereditary 
form occurring in the very young. Older children and young adults 
are more frequently affected, and in such instances there is usually no 
family history of this paralysis and the disease can be ascribed only 
to such uncertain causes as exposure, overwork, injury, or previous 
infectious fevers, including poliomyelitis of the acute type. An excep- 
tion to this rule occurs in the case of progressive muscular atrophy of 
the Charcot-Marie or leg type. This form is quite definitely a family 
disease. 

Pathology. — The essential change common to all types is atrophy 
and degeneration of the anterior cornua of the spinal cord. This 
process involves the cord vertically and is followed by degeneration of 
the peripheral nerves and the muscles which these nerves supply. 
Secondary changes in the cord substance consist chiefly of sclerosis and 
pigmentation which invade the pyramidal tracts and also, in most 
cases, the anterolateral ground-bundles. Although the cervical and 
upper dorsal regions are principally affected, the disease may also at- 
tack the lumbar region or the motor nerve-cells of the medulla, which 
supply fibers to the lips, tongue, pharynx, and larynx. Muscular 
atrophy of the leg type has been regarded as a disease of neural rather 



THE PROGRESSIVE MUSCULAR ATROPHIES 527 

than of spinal origin. This form, however, cannot be classed with the 
myopathies, and quite probably develops from primary degeneration 
in the anterior cornua. 

In a certain proportion of spinal muscular atrophies a marked 
sclerosis of the lateralcolumns supplements the usual changes secondary 
to atrophy of the cells in the anterior horns. "The degenerative proc- 
ess attacks first the terminal fibers and collaterals of the cortical motor 
neurons. It seems to destroy the tips of the nerve processes, so to 
speak, without involving the nerve-cell body itself. The next part at- 
tacked is the anterior cornual cell" (Dana). Under these conditions 
the progressive amoytrophy assumes a spastic form and is called amyo- 
trophic lateral sclerosis. 

Until the complex pathology which has just been briefly traced is 
further elucidated, the following neurologic conditions may be classi- 
fied under the general heading, " progressive spinal muscular atrophy : " 

1. Progressive amyotrophy of the hand type (or Duchenne-Aran type). 

2. Progressive bulbar paralysis. 

3. Progressive muscular atrophy of the leg type {peroneal type or Char- 
cot-Marie-Tooth type). • 

4. Progressive spinal muscular atrophy of the spastic type (or amyo- 
trophic lateral sclerosis). 

Symptomatology. — 1. Progressive amyotrophy of the hand type typic- 
ally begins as a wasting of the muscles of one thumb. The adductor 
pollicis, deep thenar, hypothenar, and the interossei muscles are pro- 
gressively involved; and as the paralysis extends, it may affect the 
flexors and extensors of the forearm, and eventually the triceps and 
deltoid and other shoulder muscles. The "claw-hand" deformity is 
common. After several months the paralysis may become bilateral, 
involving the trunk and rarely the leg muscles, or it may even develop 
into a bulbar palsy. The paralysis in the hand type of atrophy is 
usually atonic and flaccid, but may assume a spastic character, with 
exaggerated reflexes, thus simulating amyotrophic lateral sclerosis. 
The varying degrees of atony and spasticity are many. In most cases 
fibrillary contractions occur. Electric responses are diminished and 
partial or complete reactions of degeneration may be elicited. Com- 
plete reactions of degeneration belong, as a rule, to cases of rapid 
course. Occasionally rheumatoid pains and local paresthesias occur, 
but sensory disturbances are for the most part lacking. 

2. Progressive bulbar paralysis is unusual in children. Occasionally 
it marks the termination of an advancing amyotrophic lateral sclerosis 
or ophthalmoplegia. Dysphonia and dysphagia are the cardinal 
symptoms. Localized fibrillary twitchings may occur. Electric irrit- 
ability is gradually diminished. 

3. Progressive muscular atrophy of the leg type attacks first the pero- 
nei, then the anterior tibial muscles and the calf muscles, and, at a 
late stage, the adductors of the thigh and gluteal muscles. 

In cases of the so-called ascending type the arms and trunk may 
become affected. At the outset the paralysis and atrophy are uni- 



528 THE PRACTICE OF PEDIATRICS 

lateral. Fibrillary twitchings and diminished electric responses are 
observed, but there are no significant sensory symptoms. 

4. Progressive spinal muscular atrophy of the spastic type combines 
the symptoms of tonic paralysis with those of progressive wasting. 
The affected extremities are stiff and weak, reflexes are exaggerated, 
and in certain instances the lips, tongue, and larynx may be involved. 

Course and Prognosis. — In all these conditions the course of the 
disease is very chronic and extends over a period of years. The pro- 
gressive amyotrophies are apparently incurable, though remissions in 
the symptoms are frequent. Atrophy of the leg type is said to offer 
the best prognosis. 

Diagnosis. — Cases of progressive muscular atrophy in children are 
to be distinguished from those of primary myopathy, peripheral neu- 





Fig. 72. — Pseudomuscular hypertrophy. (Early case.) 

litis, acute poliomyelitis, and hereditary ataxia. The individual forms 
of amyotrophy should also be distinguished. Without attempt to 
enumerate all the factors valuable in these differentiations we may 
group together the following points: 

In the amy apathies: Family history and absence of fibrillary tremor 
and reaction of degeneration. 

In neuritis: Symmetric distribution of paralysis, possible toxic origin, 
frequent existence of sensory symptoms, and absence of family history. 

In epidemic poliomyelitis: History of acute onset and rapid course. 

In hereditary ataxia: Characteristic tottering gait, normal electric 
reactions, and hereditary influence. 

Treatment. — This is only symptomatic and palliative. Electricity 
may be applied to the wasted muscles and to the spine. The drugs 
used are calculated to exert a tonic action on the nervous system, and 



THE PROGRESSIVE MUSCULAR ATROPHIES 



529 




Fig. 73. — Pseudomuscular hypertrophy. 





L 



Fig. 74. — Pseudomuscular hypertrophy. 



34 



530 



THE PRACTICE OF PEDIATRICS 



include iron, arsenic, quinin, and strychnin. Mercury and potassium 
iodid may be tried in cases of possible syphilitic origin. 

The Progressive Amyotrophies (Primary Muscular Dystrophies) 
These include three types: 

1. Pseudomuscular hypertrophy (Figs. 72, 73, 74). 

2. Progressive muscular atrophy of ErV s juvenile type, or the scapulo- 
humeral type. 

3. Infantile myopathy of the facioscapulohumeral type, or Landouzy- 
Dejerine type. 

Etiology. — In these cases there is very frequently definite evidence 
of heredity. With the exception of the juvenile dystrophy of Erb, 
which occurs most frequently in early youth, these conditions begin to 
develop before puberty, usually between the third and tenth years. 
Pseudomuscular hypertrophy is more common in boys than in girls, 
yet is apparently transmitted through the maternal parent. While 
in many instances the first symptoms of weakness follow an acute ill- 
ness, it is doubtful whether trauma and acute diseases are truly causa- 
tive factors. 

Pathology. — According to Erb, the muscular changes are essentially 
due to trophic disturbances. In spite of this there are no demonstrable 
primary lesions in the nerves or spinal cord. In the muscles them- 
selves there is a complex degenerative atrophy which is characterized 
by a preliminary increase in the size of the muscle-fibers and the num- 
ber of nuclei, followed by disintegration of these fibers, increase of con- 
nective tissue, and lipomatosis. Although the degeneration is at- 
tended by hypertrophy, the end-result is, therefore, atrophy. 

Symptoms. — These have been conveniently outlined by Sachs as 
follows:* 

TYPES OF PRIMARY DYSTROPHIES 



Muscular Pseudo- 
hypertrophy 



Juvenile Form op 
Progressive Muscu- 
lar Atrophy (Erb's 

Type) 



Type Landouzy- 

D^Jl^RINE 



Part first affected . 

Distribution of 
hypertrophy. . . . 



Distribution of 
atrophy 



Parts remaining nor- 
mal 



Legs (calves). 

Calves, rarely 
thighs. 



Thighs, deep mus- 
cles of back, 
shoulder, and 
scapular muscles. 
Calves during 
later period ; at 
that time also 
general atrophy. 

Face, forearm and 
hand, except in 
last stages. 



Shoulder-girdle. 

Muscles around 
shoulder - girdle 
and pelvic girdle. 

Thighs, deep mus- 
cles of back, up- 
per arm. Hyper- 
trophied parts 

may become atro- 
phic in later stage. 



Face, forearm, hand 
and leg muscles, 
except in last 



Face and shoulder- 
girdle. 
None. 



Face muscles, in- 
cluding lips and 
orbicularis palpe- 
brarum; shoulder 
and scapular mus- 
cles. 



Forearm, hand, 
and legs, and deep 
muscles of back. 



* Sachs' Nervous Diseases of Children, p. 421. 



EPILEPSY 531 

The ''waddling gait/' difficulty in rising from the floor (Fig. 72), 
and large, hard calf muscles constitute the most prominent features 
of the pseudo-hypertrophic form. The ''myopathic face" distin- 
guishes the Landouzy-Dejerine type. 

In all the forms there are no fibrillary twitchings and no complete 
reactions of degeneration. The reflexes may be normal. As the pa- 
ralysis progresses they are diminished. 

Diagnosis. — The primary muscular dystrophies are not often con- 
founded with other diseases. A consideration of the history, together 
with a study of the electric and mechanical behavior of the affected 
muscles, will usually render easy the distinction between a case of 
amyopathy and one of amyotrophy. 

Course and Prognosis. — These cases extend over a period of many 
years, usually terminating in death from some secondary disease. 

Treatment. — Orthopedic measures designed to correct existing de- 
formities and complement the action of partially degenerated muscles 
afford the best results. Moderate massage and judicious use of elec- 
tricity and exercise are of value. Further treatment consists only in 
the maintenance of nutrition and the administration of drugs to relieve 
temporary symptoms as these may arise. 

EPILEPSY 

"Epilepsy," declares Spratling, "is the strangest disease in human 
history. It respects no race, no class, no age, no occupation. It may 
be in the infant at birth or delayed till extreme old age, even ninety 
years or more." Some of the most notable characters in history, in- 
cluding Caesar and Napoleon, are reported to have been its victims, 
and the existence of the affection in very remote times is proved by the 
ancient descriptions of morbus sacer and morbus comitialis. The term 
^^ Jailing sickness'^ best corresponds to Lucretius' portrayal of how the 
patient, "struck as with lightning," drops; while morbus Herculeus 
might well characterize the second stage of a severe seizure. 

Today, in spite of a growing knowledge of contributory causes, 
most potent of which are heredity and alcoholism in the parents, we 
are still ignorant of the essential nature of the disease. Statistics 
would serve to show that alcoholism in the parents is an underlying 
factor in many cases of epilepsy. Woods reports 7 cases of epilepsy 
in children which he traced to single alcoholic intoxication on the part 
of one or both parents, otherwise teetotalers. He quotes Dejerine 
who stated that 51.5 per cent, of all cases in children are due to 
parental alcoholism and but 21 per cent, to parental epilepsy, also 
Binswanger of Germany who declares of epileptics "made in Germany" 
22 per cent had their origin in chronic parental inebriations while but 
11 per cent, were due to parental epilepsy. Wood believes that it is 
not so much chronic drunkenness as drunkenness at the time of concep- 
tion that causes the transmittal of an often overwhelming neurosis 
to offspring. 

Statistics further show that from one to three persons in every 



532 THE PRACTICE OF PEDIATRICS 

thousand throughout Europe and America are epileptics, the propor- 
tion of males being slightly in excess. 

Lengthy discussions will be found in works on neurology relating 
to various features of the disease. To these works the reader is re- 
ferred, although in them he will find but little that is illuminating. 

Epilepsy is not a disease of infancy, and while cases have been re- 
ported as occurring in children under one year of age, such occurrences 
are unquestionably very rare. I have treated a large number of chil- 
dren who have had infantile convulsions and who never developed epi- 
lepsy. Neurologists are inclined to attribute a varying percentage of 
the cases of epilepsy to infantile convulsions, dentition convulsions, 
etc. The neurologist does not know of the hundreds of such cases 
seen by pediatrists and practitioners in which there is never further 
trouble. While a certain percentage of epileptics may have had con- 
vulsions in infancy, a much larger percentage of infants have convul- 
sions without further trouble. 

I agree with Koplik, who states, ''Epilepsy bears no demonstrable 
relation to infantile convulsions. The fact that the patients developed 
the disease at an early age helps in no way to explain the condition, 
and the underlying factors in epilepsy are the same regardless of the 
age of the patient. Thus what constitutes epilepsy is yet to be deter- 
mined. Various brain lesions have been found in association with epi- 
lepsy, and to them the seizures have been attributed, and yet these 
lesions and more pronounced involved areas are found at postmortem 
without the occurrence of epilepsy." 

Types. — Clinically, epilepsy may be divided into two types, petit 
mat and grand mal. 

Petit Mal.— This form may occur independently, or in association 
with grand mal. One person may be subject to both kinds of attacks. 
In petit mal there is a temporary or partial loss of consciousness with- 
out convulsion. The child may simply hesitate in his play and grow 
pale. There is a dull look in the eyes, then the attack is over, and the 
play is resumed. The attack may manifest itself in what corresponds 
to a fainting attack, in which the child loses color and sinks to the floor, 
but is normal in a few moments. 

Illustrative Cases. — A girl two years old with a good family history had two 
"fainting attacks " on two successive days. The attacks apparently consisted of a 
temporary clouding of the mentality, with a tendency to fall. During the past 
two years the child has had six of these attacks. 

In a child treated several years ago the only signs of the disease were manifested 
by a sudden cessation of play, when the patient would gaze into space for a few 
seconds only, with dilated, fixed pupils and a vacant stare. 

Grand Mal. — The epileptic attack is in most cases preceded by 
prodromal symptoms, known as "the aura,^' which consists of a warning 
by which the patient knows the attack is coming on. The aura is de- 
scribed as a peculiar sensation felt in some portion of the body before 
the attack and at no other time. 

Illustrative Cases. — A boy patient had what he described as a pain in the side. 
It was always in the same side and the area of the pain was not larger than a silver 



EPILEPSY 533 

dollar. Numbness, tingling, and a feeling of soreness in the stomach have all been 
described as constituting the aura. 

Another boy patient of eight years could always anticipate an attack through a 
feeling which he could not describe in the right leg, and which traveled up to the 
abdomen. 

In grand mal there are loss of consciousness, dilatation of the 
pupils, foaming at the mouth, stertorous breathing, and biting of the 
tongue due to spasm of the jaw muscles. The muscle spasm gradu- 
ally lessens, consciousness slowly returns, and the patient passes 
into a deep sleep. Every variation of the above symptoms may be 
encountered. 

The nature of the convulsive movement may help to determine the 
nature of the disease. Localization of spasm in one portion of the 
body or one set of muscles indicates some distinct local lesion in the 
brain. 

Diagnosis. — The diagnosis of epilepsy is not diflficult. Repeated 
convulsions after the age of infancy are always epileptic. An infant 
may have repeated convulsions and yet not have epilepsy. I have 
seen this time and again. However, if a child two or more years of 
age has repeated convulsions, even at intervals of several months, 
the condition must be looked upon as epilepsy. 

A girl of fifteen had a nocturnal attack. She is now twenty-seven. 
There have been five seizures and all at night. Cases of this nature 
constitute epilepsy just as truly as though the attacks had occurred in 
as many months. 

Diagnosis. — Diagnosis in children is easy, because children do not 
have repeated innocent fainting spells. Neither are hysteric seizures 
at all common, and when they do occur they simulate epilepsy to such 
a slight degree that a differentiation is superfluous. 

Prognosis. — The prognosis of epilepsy as to a cure is bad. The 
outlook for many of these is hopeless ; nevertheless, under a regime in- 
volving right living, proper diet, and avoidance of excitement, many 
epileptics undergo but little inconvenience. The young woman men- 
tioned above has not had an attack in twelve years. 

There are plenty of examples in history of men who were epileptics 
who have gained marked distinction. 

Treatment. — In the management of epilepsy practically all we can 
hope to do is to diminish the frequency of the attacks which character- 
ize the disease, whether it be grand mal or petit mal. Proper nutrition, 
rational habits of living, and pleasant outdoor occupations are of in- 
estimable service in the management of the epileptic. The manage- 
ment which has served me best has been directed, first, along general 
and hygienic lines; secondly, it has involved the use of drugs. Our 
aim should be to make the patient physically as normal, as vigorous, 
and as resistant to attacks as lies in our power. 

General Considerations. — Visual defects, enlarged tonsils, adenoids, 
phimosis, and irritant skin lesions must all be corrected before bene- 
ficial results are to be expected from any line of treatment. The pa- 
tient should then be placed under the best environment permitted by 



534 THE PRACTICE OF PEDIATRICS 

his station in life. Outdoor life, sports, and games are to be encour- 
aged, always within the bounds of moderation. The child should sleep 
in a cool room with the freest possible ventilation at all seasons of the 
year. If he is a school-child, he should, if possible, be instructed at 
home and given short sessions with easy studies. In work or play the 
patient should never be allowed to reach the point of mental or phys- 
ical fatigue. This, to my mind, is most important. Emotional plays 
at the theater and exciting amusements elsewhere are forbidden. 

Diet and Bowel Function. — The diet is to be adjusted to the child's 
digestive capacity. A diet suitable for the age is given, just as for the 
normal child (p. 105), meat being allowed only once a day. As intes- 
tinal indigestion and toxemia from intestinal sources are unquestion- 
ably important etiologic factors in causing a recurrence of the seizures, 
careful attention to the bowel function and diet are most important 
features of the treatment. The epileptic patient under my care is 
never allowed to pass over twenty-four hours without an evacuation of 
the bowels, and if, in the opinion of those in charge, the evacuation is 
not as copious as usual, an enema is given. If there is a suggestion of 
constipation, the treatment with the oil enemata, or other means as 
recommended for chronic constipation (p. 241), is instituted. In cases 
in which heredity and toxic influences prevail, the importance of at- 
tention to the diet and habits of life cannot be overestimated. When 
there is a focal lesion, attention to the details of living will have less 
influence, but always, surely, some influence, in diminishing the fre- 
quency and severity of the seizures by establishing a more vigorous 
physical resistance. 

Colony Management. — During the past half-century the colony 
treatment, which began in Germany with a successful private attempt 
to house four patients separately, has become widespread, and at pres- 
ent this method promises the most practical and far-reaching results. 
When parents are unable to give the patient suitable attention at home, 
I urge that he be placed in one of the excellent institutions devoted to 
the care of epileptics, where the whole manner of life is adjusted and 
regulated with one object in view. The colony management offers 
advantages that cannot be secured elsewhere. 

Drugs. — There are few drugs in the pharmacopeia, particularly 
those of a sedative nature, that have not been used at one time or 
another in the treatment of epilepsy. The bromids unquestionably i 
serve our purpose in controlling the seizures better than does any other i 
form of medication. The size of the dose is variable. Because of 
their peculiarly depressing effects upon the child's mental condition 
the bromids should be given in as small quantities as are compatible ' 
with the beneficial result desired — a diminution in the number of the 
convulsions. To a child ten years old, 10 grains of sodium bromid 
ordinarily may be given, well diluted, in one-half glass of water after 
meals. The amount may be increased or diminished as the progress 
of the case demands. If the convulsions are nocturnal, in a child of 
ten years, large doses — from 20 to 30 grains — should be given at bed- 



ACUTE POLIOMYELITIS (iNFANTILE PARALYSIS) 535 

time. In the event of the discontinuance of the drug to the point 
where it is given but once a day, the time selected should be bedtime. 
If there is continued improvement under the bromid, it may be given 
on alternate nights, and finally every fourth night. 

As ocular defects may be important factors in causing epilepsy, 
every child with epilepsy should have the eyes examined by a com- 
petent oculist. 

Illustrative Case. — I have still under my care the young woman already twice 
referred to. The first convulsion occurred at the fifteenth year. It was a typical 
nocturnal seizure. Fifteen grains of bromid with 5 drops of the tincture of bella- 
donna were given three times daily for three months, when the bromid was reduced 
to 30 grains daily. This was continued for one month, when a death occurred in 
the family which doubtless helped to incite a second attack. At this time, as the 
patellar reflex was scarcely perceptible and the bromid rash was considerable, the 
drug was discontinued. At the end of two months the daily dosage was placed at 
20 grains, with 10 drops of tincture of belladonna. This was continued for four 
weeks, when there was a third attack, without any apparent cause of an exciting 
nature beyond the fact that the patient had allowed herself to become obstinately 
constipated. This was her last attack. Twelve years have since intervened 
without a sign and without treatment for three years. 

ACUTE POLIOMYELITIS (INFANTILE PARALYSIS) 

Anterior poliomyelitis is an infectious and a transmissible disease. 

Etiology. — From the brain and spinal cord of human cases of 
poliomyelitis, as well as from experimental cases of the disease in 
monkeys, Flexner and Noguchi* cultivated, by anaerobic methods, a 
globular or globoid body smaller than any known coccus, 0.15 to 0.3/* 
in size, and staining pale reddish- violet by Giemsa 's solution. Noguchi 
also demonstrated identical bodies in films prepared directly from 
the nervous tissues. 

These cultures, when inoculated into monkeys, have caused typical 
experimental poliomyelitis. 

The virus resists freezing for a period of forty days, and drying for 
seven days, but becomes inert after exposure to 45° to 50°C. for half an 
hour. 

Pathology. — The lesions produced by the virus of poliomyelitis are, 
naturally, most marked in the nervous system, but they are present 
in other viscera as well. In the nervous system the gross lesions are 
not always very pronounced. They may appear in the spinal cord, 
pons, medulla, and cerebrum, and consist of congestion and minute 
hemorrhages, chiefly into the gray matter. The lesions of the spinal 
cord are not confined to the anterior horn. On microscopic examination 
the most marked lesions are found in the cord at the level corresponding 
to the most completely paralyzed muscle groups. The meninges show 
perivascular infiltration with round-cells, chiefly lymphocytes. The 
infiltration extends along the nerve roots and penetrates between the 
fibers. In the gray and white matter of the spinal cord there are 
focal lesions consisting of edema, perivascular cellular infiltration, 
numerous hemorrhages, and degeneration of the nerve-cells and fibers. 
The anterior horns of the gray matter show more marked lesions than 
* "Jour. Amer. Med. Assoc," 1913, Ix, p. 362. 



536 THE PRACTICE OF PEDIATRICS 

do the posterior horns, the nerve-cells being sometimes replaced by 
leukocytes. The cells in a segment are always unequally involved. 
Similar focal lesions may be present in the medulla, pons, and cere- 
brum. The intervertebral ganglia show infiltration with lymphocytes 
between the nerve-cells and fibers, and some ganglion-cells show de- 
generation and necrosis. 

The primary lesion seems to be in the meninges, and the cellular 
exudate about the vessels, with their resulting partial destruction, 
leads to secondary lesions in the nervous tissue itself. 

In other viscera the lesions consist of hypertrophy of the lymphoid 
tissue, including that of the tonsils, the thymus gland, the super- 
ficial and deep lymphatic glands, the small intestines, and the spleen* 
There are also minute focal necroses in the liver.* 

Cerebrospinal Fluid. — The cerebrospinal fluid shows changes varying 
with the stage of the disease. The cell count is almost always in- 
creased, being highest during the early days of the attack, and falling 
off progressively as the attack goes on, reaching the normal in two weeks, 
or less. In the majority of cases the fluid shows lymphocytes and large 
mononuclear cells only, but the polymorphonuclear cells may amount 
to 90 per cent, of the total. f The globulin content is increased, more 
so during the second week than the first. It may remain above the 
normal for seven weeks or more but, during the chronic stage of 
the disease, it tends to fall to normal. Draper and Peabody also found 
that the blood shows a constant marked leukocytosis, sometimes as 
high as 30,000. The polymorphonuclear leukocytes are increased 
10 to 15 per cent., while the lymphocytes are diminished from 15 to 
20 per cent. 

Blood Findings in Poliomyelitis. — The blood was studied by 
Peabody, Draper and Dochez in 71 cases of poliomyelitis. In only 
one case did they find a leukopenia. In 70 cases there was a constant 
and marked leukocytosis, sometimes ranging as high as 30,000. 

During the preparalytic stage the total leukocyte count may be 
normal, though there is a tendency toward an increase with more 
polymorphonuclears and less lymphocytes than during health. 

During the first and second weeks of the disease the leukocytes 
vary from 12,000 to 24,000 with an average of 18,000. The poly- 
morphonuclears are increased 15 to 20 per cent, and the lymphocytes 
diminished 15 to 20 per cent. Transitional and large mononuclear cells 
show no change. 

The leukocytosis continues for weeks, the average of 9 cases in the 
seventh week having been 17,250 leukocytes. 

The youngest children showed the highest leukocytosis and the 
largest number of polymorphonuclear cells. 

Transmission. — Recent advances in our knowledge of the etiology 
and pathology of anterior poliomyelitis date from the work of Land- 
steiner and Papper in 1909. They succeeded in inoculating monkeys 

* Flexner, Peabody, and Draper: "Jour. Amer. Med. Assoc," 1912, p. 109. 
t Draper and Peabody: "Amer. Jour, of Dis. of Children," vol. iii, 1912. 



ACUTE POLIOMYELITIS (INFANTILE PARALYSIS) 537 

intraperitoneally with material obtained from a fatal case of the dis- 
ease in a child. Knoepfelmacher also succeeded in producing polio- 
myeHtis in a monkey by the inoculation of human material, but these 
workers were not able to transmit the disease from monkey to monkey. 
Flexner and Lewis succeeded in doing this without difficulty, using the 
intra-cerebral method of inoculation and carrying their strains of virus 
through many generations. Flexner and Lewis were also able to trans- 
mit poliomyelitis to monkeys by means of subcutaneous and intrave- 
nous inoculation, though not in all cases were such experiments suc- 
cessful. On the other hand, intranasal inoculation in monkeys gives 
results that are always positive, while intraneural inoculation, as 
practised by Leiner and v. Weisner, is less uniformly successful. 

The Nasal Mucous Membrane. — Flexner and Lewis showed that the 
nasopharyngeal mucosa is a regular site of elimination for the virus of 
poliomyelitis in monkeys experimentally inoculated with the disease, 
and Landsteiner, Levaditi, and Pastia demonstrated the same method 
of excretion of the virus in a human patient dying during the acute 
stage of poliomyelitis. Flexner and Clark also found the virus in the 
tonsils or nasal mucosa of human cases, and Flexner has suggested 
that ''the nasopharynx acts in human beings as the portal of entry of 
the virus into the central nervous system, as well as its source of dis- 
semination to other human beings." In monkeys, and also probably 
in human beings, the virus may disappear from the nervous system 
and from the tonsils and nasopharyngeal mucosa in from eight to ten 
days after the onset of the paralysis, or it may persist there for three 
or four weeks. The observation of Osgood and Lucas, who found that 
the nasopharyngeal mucosa of monkeys was still infectious five months 
after the acute stage of an attack of poliomyeHtis, would seem to be 
exceptional and to indicate that chronic carriers of poliomyelitis may 
develop. 

The Virus. — The virus of poUomyelitis is regularly present in the 
central nervous system, and less frequently in the tonsils, nasopharyn- 
geal mucous membrane, and mesenteric lymph-nodes. It has not been 
found in the large viscera nor in the blood. The spinal fluid from a 
human case of poliomyelitis is capable of producing the disease when 
inoculated into a monkey. 

It has been pointed out that epidemics of poliomyelitis develop along 
the route of human travel. Flexner and Clark showed that stable- 
flies may harbor the virus on their bodies for a period of at least forty- 
eight hours, and that it may remain in their viscera for the same length 
of time. 

Immunity. — Flexner and Lewis proved that monkeys which have 
recovered from poliomyelitis are immune to further attacks of the dis- 
ease. They further showed that the blood of these immune animals 
contains neutralizing principles. Netter and Levaditi demonstrated 
the presence of such neutralizing principles in the blood of an abortive 
case occurring in a child. 

Type of Cases. — For clinical purpose poliomyelitis may be divided 



538 THE PRACTICE OF PEDIATRICS 

into three types: the abortive^ in which no paralysis occurs; the cerebral, 
representing the rare cases with resulting spastic paralysis; and the 
bulbar spinal group, which comprises all cases with lesions in the lower 
motor neuron, and flaccid paralysis.* 

Seasonal Influences. — While the disease may appear at any season 
of the year, a vast majority of the cases develop between July and 
October. 

Age Incidence. — Although poliomyelitis is a disease of childhood, 
cases occurring in adults are not at all uncommon. In some recent 
epidemics adults have numbered as high as 20 per cent, of the cases. 
In the 1907 New York epidemic the youngest patient reported was two 
weeks old. The most susceptible age is from the eighteenth month to 
the sixth year. Males are affected more frequently than females. 

Period of Incubation. — From five to fourteen days is generally 
accepted as the period of incubation. This observation is based upon 
the results of clinical and laboratory investigations. 

Symptoms. — As in all infectious diseases, .the symptoms vary 
widely. In a great majority of the cases there are decided prodromal 
symptoms. 

The most constant early symptom is fever. Usually there is a 
sharp rise of temperature — in a number of instances to 105° or 106°F. 
The duration of the fever is variable — from one day to a week. In 
some cases there will be a sharp, sudden rise and rapid fall. In a few 
there is slight temperature, and in others none at all. In our two 
recent epidemics of 1907 and 1916 gastro-intestinal symptoms were 
very prominent in a large number of cases. Thus there was vomiting 
and diarrhea or a sharp attack of vomiting. A peculiar feature of my 
cases has been that the severity of the gastro-intestinal symptoms has 
borne no relation to the degree of the resulting paralysis. Ordinarily 
the paralysis is not noticed until the third or fourth day of the prodromal 
stage. Pain and hyperesthesia are very prominent symptoms in many 
cases. The patient begs not to be disturbed; manipulation of the body 
and moving the limbs give rise to most intense pain. 

The nervous manifestations may be very urgent ; thus convulsions, 
apathy and stupor are not uncommon and the cases may closely resemble 
acute cerebro-spinal meningitis. In fact such an error in diagnosis is 
frequently made. When bulbar involvements predominate there will 
be facial or ocular paralysis, disturbance of speech and deglutition, and 
paralysis of the respiratory muscles. Eleven fatal cases in private 
work which came under my observation in the 1916 epidemic were of 
this type. In three cases the paralysis was limited to the bladder. 
One case was of the very unusual ascending Landry type. The feet 
were first involved and then the trunk, arms and neck. The child 
recovered after a long illness. Early in the disease, before the paralytic 
stage, the reflexes may be exaggerated. The paralysis appears from 
two to four days after the acute onset. It may involve an entire 
limb, or be limited to muscle groups irregularly distributed. The 

* Draper, Peabody, and Dochez: " Rockefeller Institute Reports," No. iv. 



ACUTE POLIOMYELITIS (iNFANTILE PARALYSIs) 539 

extent, degree, and permanency of the paralysis depend upon the 
severity of the lesion in the cord. Lesions in the lumbar enlargement 
are the most frequent and cause the greatest number of cases of 
paralysis. Involvement of the cervical enlargement causes the next 
largest number of cases. Wickman reported the distribution of the 
lesions in 868 cases as follows: 

1 . One or both legs 353 

2. One or both arms 75 

3. Combination of arms and legs 152 

4. Combination of legs and trunk muscles 85 

5. Combination of arms and trunk muscles 10 

6. Trunk muscles alone 9 

7. Paralysis of "the whole body" 23 

8. Ascending paralysis 32 

9. Descending paralysis 13 

10. Combination of spinal and cranial nerves 34 

11. Cranial nerves alone 22 

12. Localization of paralyses not given 60 

In about one-half of the cases the paralysis is limited to the legs. 
The cerebral type, in which a differentiation is difficult, presents 
clinically a symptom-complex which distinguishes it from the foregoing. 
This condition was designated as polioencephalitis by Striimpell. The 
onset in these cases is with fever, convulsions, vomiting, strabismus, 
and coma. The reflexes are usually exaggerated. 

Imbecility, epilepsy, and spastic paralysis may be the outcome. 
Cases are often designated as cerebral which strictly do not belong to 
this type. In view of the fact that the infection is a general one, 
involving the entire nervous system, cerebral symptoms are necessarily 
present in many cases. The fact that these manifestations promptly 
disappear means that no permanent lesions were present, and that the 
brain shared in the toxic systemic effects. 

That there are many cases of poliomyelitis which do not pass to 
the paralytic stage is the opinion of all observers who have seen many 
cases of the disease. In the epidemics of 1907 and 1916 several such 
cases came under my observation. Prodromal symptoms were very 
urgent in two patients who developed slight leg weakness and absence 
of patellar reflex. Both recovered in three weeks. In two others, 
a boy and girl in the family of a physician, the prodromal symptoms 
were rather mild and both developed a slight paralysis of short 
duration. 

Wickman believes that over 25 per cent, of the cases belong to this — 
the so called abortive type. There is no apparent distinction to be made 
between the symptomatology of the abortive cases and those that go on to 
the development of paralysis. Muller* believes that the abortive cases 
out-number those of paralysis. This view receives striking support from 
the recent demonstration of typical visceral lesions, indicating that there 
is a general systemic infection. With such pathologic findings, symp- 
toms such as fever and malaise are reasonably to be expected. It may 
be that the abortive cases are those in which this general process is 

* Draper, Peabody, and Dochez: "Rockefeller Institute Monograph," No. iv. 



540 THE PRACTICE OF PEDIATRICS 

present, but in which the nervous system has been spared. Netter and 
Levaditi* have demonstrated that the serum of abortive cases neutral- 
izes the virus in vitro, just as does the serum of the patients that develop 
paralysis. It is quite probable that in the past many of the abortive 
cases have not been recognized, and in certain cases at least, the appar- 
ent immunity of adults may be dependent upon such a previous, un- 
recognized attack. That the neutrahzing substance in the blood may 
persist for a long period following an attack of the disease, and probably 
immunity be present as well, is shown by the case of a man who had 
been paralyzed thirty years before, and whose serum still protected 
a monkey from the virus. 

Course. — Following the prodromal symptoms, flaccid paralysis, 
loss of knee-jerk, and atrophy appear. The paralyzed part becomes 
smaller than the corresponding limb or muscle group. The limb be- 
comes cooler than the normal. Subluxation of a joint, due to re- 
laxation of the ligaments, is not an uncommon occurrence in cases in 
which there is extensive paralysis. 

Electric Reactions. — During the onset of the disease the electric 
irritability of the affected muscles and nerves is increased. After two or 
three days, however, these nerves fail to respond to stimulation, and 
the paralyzed muscles contract only under the galvanic current, show- 
ing the typical reaction of degeneration (an anodal opening contraction 
greater than the kathodal closure contraction). Galvanic irritability 
in the paralyzed muscles may be increased for several months, but 
thereafter diminishes, and after a year or more disappears. 

Prognosis. — The prognosis in this disease must cover not only the 
mortality, but the resulting permanent paralysis as well. The mor- 
tality varies with epidemics; roughly it may be said to range from 5 
to 20 per cent. The younger the child, the less the danger to life is a 
rule borne out by experiences in many epidemics. The disease is more 
fatal after the fifteenth year. In the Springfield, Mass., epidemic, 
7 patients were over fifteen years of age. Of these, 3 died. In the 
fatal cases death usually takes place by the fifth day. 

Prognosis as regards permanent paralysis is most difficult. Cases 
with very severe prodromal symptoms may have no permanent effects. 
The degree of damage depends upon the severity of the lesion in the 
cord, and this is impossible of demonstration. I have seen cases in 
which the paralysis was complete make perfect recoveries, and other 
cases of similar nature, followed by permanent residual paralysis. A 
child of eighteen months had complete paralysis of the neck muscles 
and all four extremities. In this case the outlook apparently was 
hopeless, and yet the child made a perfect recovery. 

Permanent paralysis may follow very mild prodromal symptoms. 

The prognosis is further influenced by the possibilities of continued 

treatment. Many cases admit of much improvement through properly 

directed management continued over long periods. Among 530 

cases collected by Wickman, 56 per cent, were paralyzed, 44 per cent. 

* Netter and Levaditi: "Compt. rend, Soc. de bioL," 1910, Ixviii, 617. 



ACUTE POLIOMYELITIS (INFANTILE PARALYSIS) 541 

cured after eighteen months. In Massachusetts there were 16.7 per 
cent, of complete recoveries.* 

Communicability . — The disease is communicable by personal 
contact; this has been definitely proven under my own observation, 
during the present (1916) epidemic in this country. There had not 
been a case in a certain New England village for 25 years. Two 
children aged 3 and 6 years, came to the village from an infected section. 
Both became iU with digestive disorders and fever on the day of their 
arrival. The 3 year old girl was kept in her room and later developed 
paralytic symptoms. The older child was ill but 24 hours — a typical 
abortive case. Among the children who associated with her, one, a 
native, after 6 days developed a fatal poliomyelitis. I could give several 
other personal observations proving beyond all doubt the communica- 
bility by contact. That the disease may be carried by an intermediary 
is yet to be proven. 

Quarantine. — That the disease is spread largely through undiagnosed 
abortive cases is unquestionable. Quarantine, therefore, should be 
absolute of all suspected cases and cases that have been exposed. 
Furthermore, every child who develops an active illness with fever 
and gastro-intestinal disturbance during an epidemic should be quaran- 
tined, together with those children with whom he has previously 
associated. 

Treatment. — During the acute stage of the involvement of the cord 
our efforts count for little. We order that the child be kept quiet in 
bed, that a laxative be given, and that he receive light, easily digested 
nourishment; and then, so far as the immediate conditions are con- 
cerned, we have done our little, but our all. I have used the bromids 
and ergot and urotropin and the iodids internally, and ice-bags and 
blisters over the spine at the site of the lesion, and am yet to be 
convinced that they are worth the indigestion and discomfort they are 
apt to occasion. That the disease is due to an infection is now proved, 
and in a given case our hope must be that the infection will be mild 
in character. The outcome is determined largely by the severity of 
the infection and by the resistance of the child. 

Human Serum. — The intraspinal use of human serum from those 
who have recovered from poliomyelitis has its advocates. f My own 
observations do not warrant an endorsement of this form of treatment. 

Later Treatment. — From ten days to two weeks after the acute 
stage has passed our efforts should be directed toward maintaining the 
nutrition of the affected muscle or groups of muscles. This is to be 
done by mechanical means, electricity, and gymnastic exercises 
(p. 803). 

The beneficial action of electricity consists largely in exercising the 
muscles no longer under voluntary control, and thus increasing their 
circulation and nutrition. The immediate object of the electricity is 
to induce contraction of the muscles. Either the f aradic or the galvanic 
current may be used. The f aradic should first be tried, and if to this 

* Draper, Peabody, and Dochez: "Rockefeller Institute Reports," No. iv. 

t The intraspinal use of immune human serum in small doses, 15 c.c, combined 
with its use subcutaneously and intravenously may prove to be of value if used 
very early in the attack. 



542 THE PRACTICE OF PEDIATRICS 

there is no response, the galvanic should be used. Sittings of five to 
fifteen minutes may be desirable, depending somewhat upon the age of 
the child and the duration and extent of the lesion. The longer the 
duration of the disease, the longer should be the sittings. Once daily 
the parts should be massaged by one skilled in the work. When such a 
person is not available, the mother or nurse may undertake with some 
advantage the systematic manipulation of the affected muscles by 
kneading and rubbing. Gymnastic exercises are unquestionably of 
very much value, but must be carried out over a long period of time. 
Cases showing marked atrophy and paralysis and which promise little, 
often show surprising improvement, and restoration of function under 
properly directed exercises and manipulative treatment. The further 
management is orthopedic, and consists in the prevention of deformi- 
ties by the use of splints and braces, and their correction by teno- 
tomies and tendon transplantation. 

MULTIPLE NEURITIS 

Multiple neuritis or polyneuritis is an acute inflammatory disease 
of the peripheral nerves, degenerative in character, and usually sym- 
metric in distribution. 

Etiology. — While the great majority of cases observed in children 
follow diphtheria, this disease is by no means the only causative factor. 
The neuritis may be due to various toxic agents, bacterial and other- 
wise, producing an inflammation and degeneration of the peripheral 
nerves. Among the possible causes, other than diphtheria, are 
malaria, the exanthemata, grip, pneumonia, erysipelas, and typhoid 
fever. The toxins of the organism causing the disease are responsible 
for the nerve lesions far more often than is the organism itself. Lead, 
phosphorus, arsenic, and alcohol as possible causes are to be kept in 
mind. Lead in children is a very unusual cause. Arsenic, phosphorus 
and alcohol, however, are drugs used extensively during child life and 
should always be considered as possible etiologic factors. Instances- 
will be found in pediatric literature in which all these substances have 
been the means of causing multiple neuritis. I recently saw two pro- 
nounced cases in two brothers following very severe scarlet fever. 
Many mild cases of neuritis in children, following exhaustive diseases 
with prolonged toxemia, are doubtless overlooked, the prolonged time 
required for the return of muscle power in the arms and legs after 
disease being attributed solely to muscle weakness. 

Diphtheria. — Every child with diphtheria should be watched and 
treated as if diphtheric paralysis were expected. It has occurred to 
some extent in 9 per cent, of my cases. 

In paralysis following diphtheria the muscles of deglutition take 
precedence. There may be paralysis of the pharynx and larynx. In- 
frequently, the muscles of the extremities are affected. It is my ex- 
perience that if the heart is to be attacked, signs indicating heart 
weakness will appear early — soon after the paralysis of other parts is 
apparent, or perhaps as an earlier symptom. The first warning is the 



MULTIPLE NEURITIS 543 

heart's irregularity, and this may be the only evidence of its 
involvement. 

Pathology. — The nerves affected may show both interstitial and 
parenchymatous changes. Early in the disease there is a congestion 
of the nerve-sheaths, and multiple hemorrhages have been found in 
them. Later in the disease the nerves undergo the changes peculiar 
to degeneration in nerve structures. 

Distribution of the Lesion. — A pecuHarity of the lesion is that the 
further away the peripheral nerve structure is from the parent cell, the 
greater is the susceptibility of the nerve to the influence of the toxic 
agent. The anterior tibial group, the soft palate, and the muscles of 
deglutition are most frequently involved. 

Sensory Effects. — Sensory disturbances in children are not such 
prominent symptoms as the neurologist would have us believe, for the 
reason, possibly, that he usually sees only the more severe cases. The 
mild cases seldom come under his care. I have seen quite a number of 
the mild cases in which there were sensory disturbances and a dimin- 
ished patellar reflex following lobar pneumonia with high tempera- 
ture, and also after severe scarlet fever. 

Symptoms. — The symptoms are variable, depending upon the 
parts particularly involved. If the extremities or the neck muscles are 
affected, a careful observer will notice a gradual loss of power. The 
head is held erect with difficulty. The child is timid and refuses to 
walk. Usually there are a few falls which occasion the timidity. The 
child, if old enough, complains of weakness in the legs. In some cases 
there is nothing more than a limp to indicate the disease. Pain may 
be present, but has been of unusual occurrence in my cases. The re- 
flexes may be diminished or absent. The characteristic foot-drop and 
wrist-drop are present in severe cases. 

Cases following diphtheria are particularly prone to paralysis of the 
muscles of deglutition. The child attempts to swallow, and the food 
returns through the nose. Deglutition may be interfered with to the 
point of impossibility of swallowing. I have seen several of these 
cases. The child may not be able to walk or sit upright, or even to 
support the head. The indication of heart involvement will be an 
irregularity in its action. Cases in which the heart has been very rapid 
or very slow have been reported by other observers. In my cases the 
heart has not been particularly rapid, neither has it been slow. It is 
irregular in that for ten seconds there may be 10 beats and during the 
next ten seconds perhaps twice this number. Pronounced irregularity 
may continue for two or three weeks. 

Illustrative Cases. — A boy six years of age had a very mild attack of diphtheria, 
not of sufficient severity (in the opinion of his physician) to necessitate his remain- 
ing in bed. Two weeks after the onset of the attack, at which period he came under 
my care, there was marked paralysis of the soft palate and pharynx which rendered 
swallowing most difficult. In spite of energetic treatment with strychnin hypo- 
derm atically, the paralysis soon involved the larynx, the masseters, and the muscles 
of all the extremities. Fortunately neither the heart nor the diaphragm was in- 
volved. There was a constant flow of saliva, which at times entered the trachea 
unimpeded, causing severe paroxysms of coughing. In order to prevent this, the 



544 THE PRACTICE OF PEDIATRICS 

legs and trunk were elevated, the head being made the most dependent portion of 
the body. Swallowing was impossible, and the patient was given by gavage, every 
six hours, completely peptonized milk, whisky, beaten egg, and strychnin. The 
boy made a complete recovery, but required three months to accomplish it. 

In the case of another patient, fifteen months of age, gavage was practised at 
six-hour intervals for five days before food could be swallowed. 

Prognosis. — Complete recovery is the rule if there is no cardiac or 
respiratory involvement, although several weeks or months may be 
required to bring about complete recovery. 

Few cases of diphtheric origin recover completely under eight weeks. 

Cases showing only a slight degree of heart involvement are never 
free from danger. 

Illustrative Case. — A girl, four years, apparently well, was admitted to my hos- 
pital service with post-diphtheric paralysis of both legs, sufficient to prevent 
walking. The child, while resting on her back, dropped a top to the floor. She 
turned over and attempted to reach to the floor for the top and expired. The 
heart had previously shown some irregularity, and the child had been placed under 
close observation, which was momentarily withdrawn. 

Diagnosis. — The diagnosis is readily made through the multiple 
symmetric distribution of the paralysis, the impairment of or complete 
loss of function without impairment of sensation, and finally the dis- 
turbed respiration and cardiac irregularity. 

Electric Reaction. — The electric reactions are exceedingly variable, 
depending on the degree of degeneration in the nerves and on the varia- 
tions in this process during the progress of a case. Early in the disease 
both galvanic and faradic irritability may be increased. Faradic re- 
sponses then diminish, and though galvanic excitability is usually in- 
creased temporarily, there is ultimately a more or less complete reaction 
of degeneration. Only in the most severe cases, however, is the gal- 
vanic response completely lost. 

Treatment. — General Measures. — The management is largely pal- 
liative, as there is a strong tendency to spontaneous recovery in four to 
eight weeks from the onset. In cases due to the use of alcohol or some 
other drug, the elimination of the exciting cause will usually be followed 
by recovery. In those cases due to the toxemia of preceding disease, 
time and good care are usually all that will be required to effect a cure. 
If pain is present, the best means of relief is afforded by heat. The 
affected limb may be bound in thick layers of cotton-wool. 

Drugs. — Salicylate of soda and iodid of potash are not to be given 
to young children. They produce no appreciable effect, except possi- 
bly a disturbance of digestion and a lessening of the appetite. Should 
the pain be sufficient to interfere with sleep, bromid of soda may be 
given in doses of 8 to 12 grains for a child of five to ten years of age. 
This is best given at bedtime and should be repeated but once. In 
using hypnotics for children, one drug should not be continued longer 
than three days. 

Codein is a satisfactory sedative for a child in case the bromid does 
not suffice. Between the fifth and tenth years, from }{o to 3-^ grain of 
codein may be given at bedtime and repeated once after an interval of 
three hours. 



MULTIPLE NEURITIS 545 

As a tonic for a patient from five to ten years of age I know of no 
better combination of drugs than the following. 

I^ Strychninse sulphatis gr. 3^ 

Extract! ferri pomati gr. x 

Quininse bisulphatis 3j 

M. div. et ft. capsuloe no. xxx. 

Sig. — One after each meal. 

If constipation is present or should result from the administration of 
iron, from 3^^ to J^ grain of extract of cascara may be added to each 
capsule. The capsules are to be given for ten days, followed by cod- 
liver oil for five days. The oil should be given after meals. At the 
end of the five days the tonic capsules are to be repeated, and in due 
time followed again by the oil. This method may be followed as long 
as is thought necessary. 

Convalescence. — The patient should have the benefit of an outdoor 
life as early as possible. Electricity has not been necessary in my 
cases, nor has the use of orthopedic appliances been required. Mas- 
sage may be used with advantage after subsidence of the acute 
symptoms. It should be given by one skilled in the work. 

Treatment of Multiple Neuritis after Diphtheria. — Cases following 
diphtheria require particular mention, because of the danger of involve- 
ment of the heart, muscles of deglutition, and of respiration. If, after 
ten days from the onset of throat paralysis or paralysis elsewhere, there 
is no evidence of cardiac involvement, it will probably not develop later, 
although this is by no means certain. 

Rest. — Should the heart become involved, as shown by irregularity 
or attacks of fainting or nausea, absolute rest in the recumbent position 
is important. The patient should be constantly under the eye of an 
attendant and should not be allowed to turn over in bed or raise his 
head without assistance. 

Medication. — A hypodermic syringe loaded with Hoo grain of 
strychnin should be in readiness throughout the entire illness and well 
on into convalescence. Camphor in the dose of l}i grains in capsule 
may be kept at the bedside, ready for hypodermic use. 

In these cases we rarely have to deal with children under eighteen 
months of age,* so that in the consideration of doses only children over 
one 3^ear of age will be referred to. To a child from one to two years 
old, J^oo grain of strychnin may be given at three-hour intervals; from 
two to four years of age, from J^oo ^o Hso grain at three-hour intervals. 
After the fourth year, Jfso to }ioo grain may be given at three-hour 
intervals. When there is marked rapidity of the heart's action, with 
irregularity and restlessness in those under three years of age, from 
one to two drops of tincture of strophanthus may be given with 3^f 5 to 
Ho grain of codein, and repeated at two-hour intervals. After this 
age, one and one-half to three drops may be given with ^{q to 3^^ grain 
of codein at two-hour intervals. The codein is to be discontinued as 
soon as the restlessness ceases. For those in whom there is simply 

* My youngest patient with diphtheric paralysis was fifteen months old. 
35 



546 THE PRACTICE OF PEDIATRICS 

paralysis of the muscles of deglutition or of the extremities, small doses 
of strychnin will be all the medication required, from 3^oo to J^oo 
grain three times daily being sufficient. 

Gavage. — Troublesome features in the management of cases in which 
there is marked involvement of the muscles of deglutition, and the 
palate, pharynx, and larynx, consist in the difficulty in feeding the 
patient and in the danger of his aspirating food and mucus as a result of 
paralysis. For such patients gavage (p. 790) may be used with much 
benefit. From 6 to 10 ounces of food may be introduced into the 
stomach at four- to six-hour intervals. In using the so-called forced 
feedings, it is well to give as large feedings at one time as possible, as the 
process is always resisted by the patient. In the cases in which the as- 
piration of fluids and mucus into the larynx is a troublesome or danger- 
ous feature, the trunk should be elevated and the head lowered. 

FACIAL PARALYSIS 

Paralysis of the facial nerve is not of infrequent occurrence in the 
young. It may result from forceps pressure at birth or from pressure 
exerted by the bony parts of the pelvic outlet. In later infancy or 
childhood it may be the result of trauma caused by operative manipula- 
tions, it may be of rheumatic origin, it may be due to cerebellar disease, 
or to exposure to cold. In one of my patients the paralysis was attri- 
buted to sitting by an open window in a railroad car on a cold day. 
The nerve, in its outward passage through the Fallopian canal, may be- 
come diseased from the presence of a purulent otitis media. This is 
probably the most frequent cause of facial paralysis. Facial paralysis 
may be caused by poliomyelitis. During the 1916 epidemic a vast 
number of cases showed facial paralysis — many without other paralytic 
signs. In others the paralysis was associated with other lesions. 

Prognosis. — The prognosis depends largely upon the cause of the 
paralysis. Cases due to exposure to cold, and rheumatism, and those 
in the newly born that are due to birth trauma usually terminate in 
recovery. 

Cases resulting from section of, or other injury of the nerve, through 
accident at operation, likewise almost always have a satisfactory out- 
come. The unfavorable cases are those due to brain disease, such as 
meningitis or tumor, or to severe injury, such as fracture or caries of the 
temporal bone. 

Treatment. — The management depends entirely upon the cause of 
the paralysis. If the condition is due to cerebral disease, but little is 
to be expected from treatment. If it is due to an otitis media, sur- 
gical procedures, such as establishing a free drainage from the cavity of 
the middle ear, followed by frequent hot irrigations, should be employed. 
If these are ineffective, the mastoid should be opened and the 
cavity drained posteriorly. When the functional activity of the nerve 
is delayed, electricity may be brought into use in the manner indicated 
below. Cases in which rheumatism is supposed to be a. factor should 
be given the benefit of antirheumatic treatment by the use of the 



erb's palsy (obstetric paralysis) 547 

salicylates (p. 711). In the cases due to cold or trauma there is a 
strong tendency toward recovery without treatment. 

It is difficult to judge of the value of such a therapeutic measure as 
electricity; but the effect of exercising the paralyzed muscles and 
stimulating nerve conduction by its use must be of some service. If the 
electricity is used, five-minute daily sittings are all that are necessary. 
The faradic current should be employed if it produces sufficient re- 
action; if not, the interrupted galvanic current. 

ERB'S PALSY (OBSTETRIC PARALYSIS) 

This disease is due to a traumatic neuritis caused by an injury of the 
brachial plexus during labor. 

Lesion. — The injury may be very slight, causing but a temporary 
paralysis, or very extensive, causing subsequent degeneration of the 
nerve structure. The essential lesion in Erb's palsy is an injury of the 
fifth and sixth cervical nerve-roots near their junction on emergence 
from the spinal cord. This injury may involve rupture, laceration, or 
bruising of the nerves, and occasionally hemorrhage between the fibers. 
In typical cases the seventh and eighth cervical nerves are not injured, 
but occasionally these also may be damaged. The muscles principally 
affected by the paralysis are the deltoid, biceps, brachialis anticus, 
supinator longus and supinator brevis, the spinati, and coraco- 
brachialis. The pectorals, latissimus dorsi and triceps may be par- 
tially affected. 

Diagnosis. — The chief point in the diagnosis is that one arm alone is 
involved. Cases of bilateral involvement are extremely rare. In dif- 
erentiating this form of paralysis from cerebral palsies it will be noted 
that there is a flaccid paralysis with some degree of atrophy. There is 
never spasticity, and the mentality is normal. After a few months the 
affected limb becomes smaller and much softer than the unaffected arm. 
Owing to the location of the muscles involved and because of the paraly- 
sis of the supinator group, the arm is often rotated inward, throwing the 
palm of the hand outward and backward. Owing to paralysis of the 
extensors, due to involvement of the musculospiral nerve, the fingers 
and thumb are in a more or less permanent condition of flexion-fixation. 

Prognosis. — In the main the prognosis is favorable, but not as fa- 
vorable, from my observation, as the literature would lead us to believe. 
In fact, a guarded prognosis should always be given. I have seen com- 
plete recoveries. A case involving fracture of the humerus with com- 
plete paralysis underwent complete recovery in three months. I have 
seen partial recoveries in other instances, and again other cases in 
which the lesion was of such a nature as to make recovery impossible. 
We may safely say that all the subjects improve and that they may 
recover entirely, but we are not in a position to promise any outcome 
in a given case. Improvement should not be despaired of even after 
several months have elapsed. I have known cases in which the im- 
provement continued to the eighth and tenth year. In a few cases the 
paralysis and deformity are permanent. If there is complete paraly- 



548 THE PRACTICE OF PEDIATRICS 

sis after one year it may safely be assumed that the paralysis will be 
permanent. 

Sachs states that even in the event of complete paralysis, recovery 
may be looked for in the cases showing a slight response to faradism, 
in two or three months. When there is no faradic response, but re- 
action to the galvanic current, the restoration of power may be expected 
in six months. In those cases in which there is no galvanic or faradic 
response, a year or two may be required before the arm is normal. 

Treatment. — The atrophy and contractions which develop are 
determined largely by the extent of the injury, and to a lesser degree 
by the treatment. During the first three weeks in lifting and handling 
the infant the arm should be protected from other injuries, such as may 
take place in bathing and the other manipulation necessary in the care 
of the baby. After this time massage of the entire arm and shoulder 
with lanolin should be practised at least twice a day, from ten to fifteen 
minutes at a time. After two weeks electricity may be used for a few 
minutes each day. If the child can bear it, the faradic current answers 
best. In case, however, there is no response to faradism, the galvanic 
current should be used. Under massage and electricity the improve- 
ment in the arm is often most satisfactory. It is not well, however, to 
promise the parents that a normal arm will be the outcome. I have 
seen cases in which there was complete restoration of power after it had 
been entirely lost, while in others the arm was permanently disabled. 
The degree of improvement is dependent upon several factors, the chief 
one of which (the extent of the nerve injury) is in every case uncertain. 

Operative measures, consisting of grafting and transplanting of the 
nerve, have recently been advocated by many surgeons. Sharpe* of 
New York recommends this procedure in cases with complete paralysis 
at the end of one month. 

Such a degree of paralysis means that there has been an extensive 
injury and tear in the plexus. In such an instance there is bound to 
be an impaired arm. The early operation is advised in order to head 
off the formation of large masses of fibrous tissue. The earlier the 
anastomosis of the nerve roots, the more perfect the union of the torn 
nerve structures and consequently a better ultimate result. 

An important feature in the management of these cases consists in 
the prevention of deformity through contractures. This may be ac- 
complished by the use of suitable orthopedic appliances. 

The value of manipulation treatment and electricity is difficult to 
determine. Dispensary cases in which no treatment of moment was 
carried out have made very satisfactory progress, providing contrac- 
tures and deformities were not allowed to develop. 

FRIEDREICH'S ATAXIA (HEREDITARY ATAXIA) 

Friedreich was the first to describe this affection and establish a 
clinical entity. The designation, ''hereditary ataxia," is faulty for the 
reason that heredity does not necessarily enter into consideration. 
* Journal A. M. A., March 18, 1916. 



Friedreich's ataxia (hereditary ataxia) 549 

Two brothers, aged four and six years, developed the disease; the 
family history was otherwise perfect. This disease, however, shows 
a tendency to family selection. Gowers refers to 65 cases occurring in 
19 families. The number of cases in one family was as high as 10. 
Gowers finds the sexes about equally divided as regards liability. 
Sachs, in a wide experience, has never seen a case in a girl. 

Pathology. — Neurologists agree that the pathology of Friedreich's 
disease is not well understood. Sachs states that ''one fact is indis- 
putable, in microscopic examinations a sclerosis of the spinal cord is 
found involving at different levels or at one and the same levels various 
systems of the cord. The sclerosis affects most frequently the posterior 
columns or the lateral columns or both together, and hence the symp- 
toms vary between those of a pure posterior spinal sclerosis and those 
due to a posterior lateral sclerosis, resembling the symptoms of the 
ataxic paraplegia of the adult." 

Symptoms. — Walking is early interfered with, and the child stands 
with difficulty. The gait is peculiarly ataxic. The feet are placed 
widely apart, and the patient's attempts at locomotion are attended 
with uncertainty and hesitancy. Romberg's sj^mptom was present in 
the two boys referred to. Neurologists tell us that this symptom is 
variable. 

Incoordination in the use of the arms is present, not unlike that in 
chorea. Attempts at a concise volitional act with the upper extremi- 
ties — such as writing, bringing the ends of the index-fingers together, or 
placing the tips of the fingers on the tip of the nose — result in hesitancy, 
tremor, and imperfection in the act attempted. In fact, the act can be 
accomplished only with much effort and after several attempts, if at all. 

Sensation is not greatly interfered with. 

As the disease progresses choreic movements of the head and face 
develop. The Babinski reflex is usually present. The patellar reflex 
is lost. There is gradual loss of muscle power and later emaciation. 

The patient is mentally slow and diffident. There is an entire loss 
of confidence, and this is stamped on the countenance and is manifested 
in every voluntary act. The child hesitates and speaks slowly, as 
though ideas were hard to formulate into words. 

The eye changes are not important. Nerve atrophy does not occur, 
and the Argyll Robertson pupil is absent. 

Prognosis. — The disease is slowly progressive and fatal, although 
several years may be required before the fatal termination, which is 
usually the result of intercurrent disease. The duration of the ataxia 
is rarely longer than ten years. The patient may succumb before the 
fifth year. 

Differential Diagnosis. — True tabes may be differentiated from 
Friedreich's ataxia by the absence of mental impairment and spinal 
defects, both of which conditions belong to Friedreich's disease. The 
Argyll Robertson pupil is present in tabes and absent in Friedreich's 
ataxia. Choreic movements of the upper extremities are the rule in 
Friedreich's disease and absent usually in tabes. 



550 THE PRACTICE OF PEDIATRICS ^ 

Treatment. — No known form of medication is of value. All that 
may be accomplished in the treatment relates to the comfort of the 
patient. 

ACUTE INFECTIVE MENINGITIS 

Acute meningitis, as its name implies, is an acute inflammation of 
the meninges covering the brain and cord. 

Etiology. — Acute meningitis may be either a primary or a secondary 
disease. The more common sources of acute meningitis are suppura- 
tion in the ears, nose, and eyes, head injuries, and systemic infections 
with a bacteremia such as typhoid, influenza, pneumonia, and infective 
endocarditis. 

When primary, meningitis is usually due to the meningoccus or the 
pneumococcus. 

Cases of secondary origin are usually the result of the invasion of 
the staphylococcus. The streptococcus, colon bacillus, typhoid and 
influenza bacillus may also be included in the latter group, the 
cerebral involvement following pneumonia, or an intestinal infection 
or typhoid fever. Streptococcus or staphylococcus meningitis is often 
a complication of middle ear, mastoid, or sinus disease. 

Pathology. — The changes occurring locally in and about the brain 
depend on the character and source of the infection. In ear infections 
the lesions are often unilateral and accompanied by a sinus thrombosis. 
In the majority of the other cases the vessels of the pia are congested and 
give origin to small hemorrhages, and the surface of the brain is covered 
with seropurulent or fibrinopurulent exudate; the convolutions are 
flattened to a degree depending on the amount of associated hydro- 
cephalus. Accompanying cord-involvement is the rule. The presence 
of a large amount of greenish-yellow exudate over the anterior portion 
of the cerebral cortex, with many fibrinous adhesions,is very character- 
istic of pneumococcus meningitis. In certain infective fevers, such as 
measles and scarlet fever, acute serous meningitis may occur. 

In a private case due to the pneumococcus the anterior half of the 
brain cortex (see Plate I) was incased in pus. 

Symptoms. — If the case is primary and due to the pneumococcus, 
the onset may be sudden, with vomiting and convulsions, both of which 
may be repeated many times. With the active manifestations there 
will be at first drowsiness, followed by stupor from which the child can 
with difficulty be aroused. Usually the active symptoms, such as 
vomiting and convulsions, are absent in the secondary cases. 

The first indication of cerebral involvement will be drowsiness, 
stupor, irregular respiration, and irregular pulse. A disturbance of the 
heart action is a very significant and early sign. It may be irregular, 
intermittent, or it may be very rapid and regular. I have repeatedly 
seen the heart action at 140 to 180 a minute, with practically a normal 
temperature. Vasomotor disturbance indicated by the tache cere- 
brale may be an early symptom. A tense fontanel is rarely absent, and 
is one of our most valuable signs. The pupils are usually dilated sym- 



PLATE I 




Pneumococciis meningitis. 



ACUTE INFECTrV'E MENINGITIS 551 

metrically or unevenl}?-, and show little or no response to light. Hyper- 
esthesia and rigidity of the neck may be present. 

Purposeless movements of the leg or arm are often seen when the 
symptoms of the disease are well marked. The leg or arm is raised and 
allowed to fall; this is repeated for hours at a time. An elevation of 
temperature is usually present. It may be high, low, or variable. 
Swallowing is early interfered with. 

In the patient above referred to, whose brain is shown in Plate I, 
the first sign was a temperature of 102°F., a greatly distended fontanel, 
and stupor. The child died in three days, aged seven months. 

Diagnosis. — There is no characteristic temperature range. The 
only positive information as to the nature of the infection is obtained 
by lumbar puncture ; only in this way can a positive differential diag- 
nosis between acute simple, tuberculous, and cerebrospinal meningitis 
be made. 

In many severe diseases in which there is marked toxemia, symp- 
toms closely resembling meningitis will be in evidence. In pneu- 
monia, in the severe intestinal infections, and in heat prostration the 
cerebral symptoms so closely simulate those of meningitis that a posi- 
tive diagnosis without lumbar puncture may be impossible. Before 
the advent of lumbar puncture I have seen most excellent clinicians 
diagnose meningitis in cases which at autopsy showed no pathologic 
condition in the brain. I have further known cases so diagnosed to 
recover too promptly to be a comfort to the attending physician. 

Differential Diagnosis. — Acute simple meningitis, tuberculous 
meningitis, cerebro-spinal meningitis, anterior poliomyelitis and men- 
ingismus may all show certain symptoms in common, sufficient to re- 
quire a lumbar puncture with examination of the spinal fluid, cultural 
and otherwise, in order that a positive diagnosis be made. In acute 
simple meningitis the fluid is usually turbid, and when allowed to 
stand, a considerable deposit of pus forms in the tube, bacteriological 
examination of which determines the nature of the infection. The 
cells present in the fluid are almost exclusively polymorphonuclear 
leucocytes. In meningismus there are the signs of drowsiness, stupor, 
and perhaps hyperesthesia and immobility of the pupils, but no irregu- 
larity of the pupils and rarely irregular respiration and distention of 
the fontanel. Particularly significant in such cases is the absence of 
signs of irregularity or slowness in the heart action. Acute simple 
meningitis may closely resemble that due to the meningococcus 
(cerebrospinal), particularly if the influenza bacillus or the pneumococ- 
cus is the infecting agent. 

Prognosis. — The prognosis is most unfavorable. I have yet to see 
recovery in a case in which the diagnosis was proved by lumbar punc- 
ture. Occasionally such recoveries are reported. 

Treatment. — The most one can do in acute simple meningitis is to 
nourish the patient and lessen his discomfort. We have no means of 
treatment that may be considered in any sense curative. By the use 
of repeated lumbar puncture we can in some cases make the patient 



552 THE PRACTICE OF PEDIATRICS 

more comfortable, and perhaps aid him to resist the infection. The 
pulse and the respiration improve, as well as the urgency of the nervous 
phenomena; the opisthotonos and the excessive hyperesthesia may be 
temporarily relieved. There is no rational ground, however, for ex- 
pecting the withdrawal of the cerebrospinal fluid to be curative; nor 
may the injection of disinfectant drugs into the canal be expected to 
aid in controlling the disease. 

Lumbar Puncture. — Lumbar puncture (p. 566) may be practised as 
frequently as once in twenty-four hours, the frequency of such proce- 
dure depending, of course, upon the condition of the patient and the 
relief afforded. The use of lumbar puncture more frequently than 
once in twenty-four hours, as has been suggested by some writers, is 
not, however, to be advised. The amount of fluid to be withdrawn 
depends upon the pressure in the canal as indicated by the passage of 
fluid through the cannula, from one to three ounces being the usual 
amount withdrawn. Strict surgical precautions as regards asepsis 
should be observed in performing the operation. One dram of aristol 
in one ounce of collodion, applied with a camel's-hair brush, makes 
a suitable protective dressing after the withdrawal of the cannula. 

Warm Packs. — The v^^arm pack or warm bath at 105°F., by lessen- 
ing the cerebral blood-pressure, may also assist in relieving the more 
active nervous manifestations. If the bath is used, the child should 
not be kept in it longer than three minutes. I usually prefer the hot 
pack. A large bath-towel or medium-weight flannel sheet is wrung out 
of water at 110°F. and wrapped around the child's body from the 
waist down. This is repeated at half-hour intervals for three hours, 
when, after a period of rest for an hour or two, the packs may be re- 
sumed. 

Diet. — The proper nutrition of the patient with meningitis is often 
a matter of no little difficulty. The child may either refuse the food, or 
be unable to swallow. Nutrition by means of the rectum or colon may 
be of assistance for a few days, but cannot be relied upon for long 
periods for the reason that the parts become intolerant and the nutrient 
enemata are expelled. Feeding by means of gavage is always to be 
employed when other means fail. The younger the child, the more 
applicable this method. The feeding should not be attempted oftener 
than at four-hour intervals; usually, feeding every six hours suffices. 
Completely peptonized full milk (p. 69) is usually given in quantities 
suitable for the age. After a few trials of gavage the patient may take 
the nourishment by the usual method, or the gavage may be kept up 
indefinitely. 

Sedatives. — Sedatives may be employed with a view to saving the 
strength of the patient. Morphin, codein, the bromid of soda, or 
chloral may be given. As morphin and codein increase the usual 
existing constipation, their use should be very temporary. The 
bromid of soda for the cases which may require the protracted ad- 
ministration of a sedative answers better than any other form of medi- 
cation. To an infant under eighteen months of age, from 2 to 4 grains 



TUBERCULOUS MENINGITIS 553 

may be given at intervals of two to three hours, according to the results. 
In case the nervous symptoms are very urgent, Y^ to 1 grain of chloral 
may be added. Should administration by mouth be impracticable, the 
sedative may be given by rectum, by means of a rectal tube inserted 
at least 9 inches. In using the bromid and chloral in this way twice 
the amount of chloral and thrice the amount of bromid employed 
in stomach administration should be given. After the eighteenth 
month, from 1 to 2 grains of chloral and from 4 to 8 grains of the bromid 
well diluted may be given by the stomach, and repeated as often as may 
be necessary. In case the medication is to be given by rectum, it 
should be diluted with at least 4 ounces of water, and proportionately 
more given, as suggested for younger children. 

TUBERCULOUS MENINGITIS 

Tuberculous meningitis is one of the most fatal diseases of childhood. 
As its name implies, it is a tuberculous inflammation of the meninges. 
The frequency of the disease is due to the favorable field offered by the 
covering of the brain for bacterial growth and the wide dissemination of 
the tubercle bacillus. The rapid development of the brain, the birth 
weight of which is increased about four times, during the first four 
years of life, necessitates rapid development and active work on the 
part of the blood-vessels, and lymphatics. These, therefore, supply a 
favorable culture field for the invading organism. 

Age. — No age is exempt. My youngest patient was three months 
old. Between the first and third year the greatest number of cases 
occur. The disease is rare after the eighth year. I have seen four 
cases between the twelfth and the eighteenth year. 

Pathology. — This form of meningitis is usually secondary to tuber- 
culosis elsewhere in the body, and is very usually part of a general 
miliary infection. Out of 413 fatal cases of tuberculosis in children, 
Shennan reports tuberculous meningitis in 184, or 44.5 per cent. In 
77 of these cases the disease had spread from mediastinal glands; in 26, 
from abdominal glands; and in a small number, from an active pul- 
monary inflammation. Transmission is practically always through 
the blood. Miliary tubercles may be numerous on the walls of the 
blood-vessels of the pia mater, over all surfaces of the cerebrum, 
cerebellum and cord, but they are usually most numerous at the base, 
between the peduncles. There may be more or less exudate of fibrin 
and leukocytes at the base. The spinal fluid is increased in amount 
and, owing to the closure of the foramen of Magendie by inflammatory 
exudate, the lateral ventricles become dilated. The ependyma may 
contain many miliary tubercles. Flattening of the cerebral convolu- 
tions may result from accumulation of fluid in the ventricles. 

Symptomatology. — Tuberculous meningitis is variable in its early 
manifestations. Probably one of the earliest indications of the disease 
is a change in the disposition of the patient. A happy, easily pleased 
child becomes cross and disagreeable, and maj^ remain for days in this 



554 THE PRACTICE OF PEDIATRICS 

condition. In getting the history of a case I have repeatedly heard 
these symptoms brought forward. 

Illustrative Cases. — A girl patient, three years of age, was in the habit of going 
to the park daily. On her return home, regardless of the street selected by the 
nurse, the child insisted on turning back and passing through another street. 
The child was very irritable and refused to play with other children. The mother 
had been in the habit of singing several songs to the child. The child selected one 
and would have no other. She was not content out of the mother's arms, and 
insisted that the song constantly be sung to her while awake. The mother became 
nearly distracted at the constant performances, and at this time, after three weeks 
of decided mental aberration on the part of the child, brought her under my care. 
The child died five weeks later from tuberculous meningitis. 

Two cases have recently come under my observation in which the first symptom 
and the only symptom for two weeks was intense headache. 

There may be vomiting without apparent cause, and if the vomit- 
ing is repeated one or more times on successive days and associated with 
other suggestive signs, it constitutes a symptom of no little value. 

Convulsions may usher in the disease. The convulsions are apt to 
be repeated several times. 

Mental disturbance, vomiting without apparent cause, convulsions, 
loss of appetite, constipation, restlessness at night, and night-cries 
belong to the earlier manifestations. After a week or perhaps two weeks 
of pronounced though indefinite signs the child becomes dull and 
apathetic, sleeps a great deal, and rapidly passes into a condition of 
semi-stupor from which he is aroused with difficulty. Hyperesthesia 
and exaggerated reflexes may be present early in the disease. With 
the progress of the case they often disappear. The fontanel early be- 
comes tense and bulging — a very valuable sign. 

Decided evidences of cerebral pressure now make their appearance. 
The respiration becomes irregular. The pulse-rate is 60 to 80 instead 
of 100 to 120. At times the pulse will change very markedly and be- 
come rapid for a few hours; as a rule, it is characterized by slowness 
and irregularity. Rigidity of the neck, slight opisthotonos, and spas- 
ticity of the extremities appear. During this time the child will usu- 
ally swallow if food is given. In many cases there is an incoordinate, 
almost perpetual motion of the arm and leg on one side of the body. 
The pupils become sluggish, responding slowly to light stimulation, 
or fail to show any response. The pupils may be unequal. One pupil 
may respond to light while the other remains stationary. 

There is no characteristic temperature in tuberculous meningitis. 
The usual range is between 99° and 102°F. It may be higher or lower. 

Very few cases of uncomplicated tuberculous meningitis occur, as 
mentioned before. The meningitis is usually associated with tuber- 
culous processes elsewhere, which exert a controlling influence on the 
temperature. 

Later Symptoms. — The coma increases. It is impossible to arouse 
the child. Liquid food placed in the mouth remains there or runs out 
at the sides. The breathing is labored. Cheyne-Stokes respiration 
develops. The pulse becomes slower and intermittent and irregular 
and the child dies. 



TUBERCULOUS MENINGITIS 555 

Regardless of the age, the signs and symptoms are very similar. 

Occasionally one meets with fulminating cases with sudden onset 
Tvith urgent symptoms of vomiting, high fever, rapidly developing stu- 
por, and irregular pulse and respiration. Such cases are rare, and 
when they occur, are easily confused with those of cerebrospinal 
meningitis. 

Diagnosis. — Early positive diagnosis is impossible unless the case 
is a very active one. With the development of pressure signs, certain 
phenomena appear which point very strongly to the nature of the 
disease. 

Rigidity of the neck is usually present in some degree. When the 
child's head is raised from the pillow, the entire body may be elevated 
accordingly. 

Fulness of the fontanel (in case the fontanel has not become closed) 
is always present in greater or less degree, and is a sign of much value. 

Slow, irregular pulse, and slow, uneven respiration are symptoms of 
great diagnostic value. Rarely does a case pass through its various 
phases without showing these phenomena. 

Drowsiness, gradually increasing, followed by stupor and coma, is a 
constant manifestation. 

Unequal, inactive, usually dilated pupils will be found in cases well 
advanced. 

Repeated vomiting without apparent cause, in the presence of sug- 
gestive signs, supplies valuable corroborative evidence. 

The Kernig sign consists of an inability to extend the leg on the thigh 
when the thigh is flexed on the abdomen. This symptom is present in 
nearly all cases late in the disease. 

The Babinski reflex and Oppenheim's reflex, about which much is 
written, are of very little value; if present, they corroborate other 
findings. Their absence means nothing. True, they may be present 
in a certain proportion of cases of tuberculous meningitis, but thej^ are 
present in tetany and so-called tetanoid states from whatever cause, 
and they may also be present in brain injury and in spastic paraplegia 
due to birth trauma. 

The temperature range is of no value in diagnosis for reasons 
already given. Optic neuritis is present in a majority of the cases 
late in the disease. Tubercles in the choroid will be found in most 
cases. 

Lumbar Puncture. — A positive diagnosis can be made only by 
lumbar puncture (p. 566) . Tubercle bacilli would be found in the spinal 
fluid in practically all cases of tuberculous meningitis, although it may 
be necessary to make more than one examination. In withdrawing 
the fluid, that which is drawn last should be collected for the examina- 
tion. The test-tube, in which 10 to 15 c. c. of fluid has been drawn, 
should then be allowed to rest at room-temperature for twelve to 
eighteen hours, when a delicate clot of fibrin will have formed in the 
fluid. The fluid is not to be agitated. The fibrin may then be 
removed and examined by the usual methods for the detection of 



556 THE PRACTICE OF PEDIATRICS 

tubercle bacilli. The spinal fluid shows lymphocytosis and the globulin 
test is positive. 

In one case occurring under my care the tubercle bacilli were not 
found until the tenth examination was made. The child had all the 
usual symptoms of meningitis, and there were tubercle bacilli in the 
bronchial secretion; the examinations were, therefore, persisted in. 

The appearance of the fluid withdrawn is suggestive, being bright 
and clear or slightly opalescent in tuberculous meningitis, while in 
other forms it is usually turbid and cloudy. The globulin and cellular 
content of the fluid are both increased and the leukocytes present 
are 90 per cent, mononuclear. 

Differential Diagnosis. — The first problem in a given case is to de- 
cide whether there is a meningitis and whether the signs are such as 
to warrant further investigation. Such being the case, a differentiation 
as to the type we are dealing with is necessary, and here again lumbar 
puncture must be brought into use. While we may, with a consider- 
able degree of accuracy, judge as to the nature of the infection, cases are 
frequently encountered in which a differentiation is impossible without 
lumbar puncture. 

We may have a very active condition due to the tubercle bacillus 
which may be readily confused clinically with meningitis of the cere- 
brospinal type. Again, I have seen several proved cases of mild cere- 
brospinal meningitis which surely would have been diagnosed as tu- 
berculous without the proof supplied by the lumbar puncture. In 
tuberculous meningitis the Von Pirquet test is always positive. 

The most frequent error made is in the cases of grave systemic 
poisoning with active cerebral manifestations. In pneumonia, scarlet 
fever, heat prostration, and in the acute intestinal infections, the 
stupor, the convulsions, and vomiting often are interpreted as due to 
meningeal involvement. In toxic cases of such a nature the evidence 
supplied by the absence of the distended fontanel, the absence of eye 
symptoms, and the absence of the respiratory and pulse phenomena 
point strongly to a meningismus and not to a meningitis. It must 
be remembered that any cardinal symptom of meningitis may be pres- 
ent in one of these acute toxic processes. In meningitis, however, 
we have a grouping of symptoms — a symptom-complex which renders 
a diagnosis practically positive. 

Prognosis. — The prognosis is most unfavorable. I have seen a 
large number of cases, both in hospital and private work, and have 
never known a recovery of a proved case. Recoveries have been 
reported, however, by competent observers. 

Archanzelsky, of Moscow, reports the recovery of a girl eight years 
of age who showed the characteristic symptoms of the disease, and in 
whose cerebrospinal fluid a large number of tubercle bacilli were found. 
This writer found in the literature instances of recovery in 50 cases of 
tuberculous meningitis the existence of which he considered proved. 

Duration. — The duration of the disease varies. Few cases pass the 
third week. I have seen patients die within one week from the onset. 



CEREBROSPINAL MENINGITIS 557 

My longest case was in a girl three years old, who lived six weeks from 
the onset of the symptoms. 

Treatment. — I know of no treatment that is of curative value. 
For the comfort of the family and the relief of symptoms the meas- 
ures suggested under the treatment of simple meningitis (p. 552) 
may be followed out. 

Withdrawal of the cerebrospinal fluid, removing the pressure within 
the cranium, may furnish temporary relief from the very active symp- 
toms of convulsions, restlessness, and muscle contractions. The fluid 
returns, however, and the fontanel, which was sunken after the 
tapping, is soon bulging as much as before. The therapeutic value 
of the lumbar puncture, according to my observation, is nil. 

CEREBROSPINAL MENINGITIS 

In 1866 Samuel Webber recorded over a score of epidemics occur- 
ring between the fourteenth and nineteenth centuries, which presented 
the features of this form of meningitis, giving rise to such designations 
as *' typhus syncopalis" ''petechial fever," fievre cerebrale," and 
''cephalogie epidemique." 

Danielson and Mann describe an epidemic which attacked Massa- 
chusetts in 1806, and in 1811 Elisha Hirth published a very full 
account of ''a malignant epidemic called ''spotted fever J' Since this 
period, according to Dr. A. Jacobi, outbreaks of the disease have been 
more extensive in America than in any other country. In the years 
1904 and 1905 New York city underwent a very severe epidemic, which 
caused about 3400 deaths, and in the winter of 1904 attained a mor- 
tality of 91 per cent. At this time a commission appointed to investi- 
gate the disease reported the presence of the meningococcus, as shown 
by cultures from the nasal mucosa, in 50 per cent, of the patients and 
in 10 per cent, of their attendants. This organism, also known as 
the Diplococcus intracellularis of Weichselbaum, was discovered in 
1887. Heubner first showed the existence of the same agent in the 
spinal fluid of a living patient. 

Cerebro-spinal meningitis occurs sporadically and in epidemic form. 

The extreme irregularity remarked by many observers in the spread 
of epidemic meningitis has led one to state that "from the practical 
clinical standpoint the etiology is about the same as for death by light- 
ning." In the past the mortality has ranged from 50 to 100 per cent. 
With the adoption of serum therapy, however, the death-rate has been 
universally lowered, and in 1908 Flexner and Jobling were able to 
report a total of nearly 400 cases in which their serum had been used, 
with a mortality of only 25 per cent., while in the cases most promptly 
treated the death-rate was considerably lower. 

Bacteriology. — The disease is due to the Diplococcus intracellularis 
of Weichselbaum, which has become known as the Meningococcus intra- 
cellularis, and is universally acknowledged as the infecting agent in 
the disease. 



558 THE PRACTICE OF PEDIATRICS 

This organism had been found in the blood, lungs, and joints. It 
has never been demonstrated as existing outside of the body. 

Pathology. — Meningococci are not all identical in their serological 
reactions; but fall into two main groups which have been termed ''nor- 
mal'^ and parameningococcus'' strains. Many strains should be em- 
ployed in making a polyvalent serum for therapeutic use, in order that 
immune bodies in both groups of meningococci may be produced. The 
parameningococci were first described by Dopter, who isolated them 
from the nasal secretion and later they were found in the spinal fluid 
of cases of cerebro-spinal meningitis. There are no morphological nor 
biological differences between the two types of meningococci. 

Notwithstanding the general nature of this disease, as shown by 
its fulminant course and the existence of such symptoms as petechise,. 
purpura, and herpes, the lesions produced are quite closely limited 
to the central nervous system. Here the conditions found in cases 
of simple meningitis are roughly simulated. Enlargement of the 
spleen, multiple abscesses, acute nephritis, hepatic degeneration, and 
pneumonia may also be found. 

The exudate covering the brain is usually lighter in color and 
thinner than in pneumococcus meningitis and in sporadic cases of the 
meningococcus type. The cord and base of the brain only, or even the 
cord alone, may show the presence of the lesions. The affected por- 
tions of the brain are covered with seropurulent or fibrinopurulent 
exudate, and the cerebral convolutions are more or less flattened,, 
depending on the degree of accompanying hydrocephalus. 

The hydrocephalus is caused by closure of the foramen of Magendie 
by inflammatory exudate, either recent or organized. 

In very malignant cases the gross changes in the meninges are not 
marked because the disease runs its course so rapidly, but the mem- 
branes show congestion and dulness and microscopically many 
polynuclear leukocytes and cocci are found on the surface of the 
pia arachnoid. 

The Cerebrospinal Fluid. — The cerebrospinal fluid is turbid. Whe- 
ther it is greatly increased in amount or not depends upon the severity 
of the infection. The cells present are polynuclear leukocytes and 
meningococci are found within them and outside as well. 

Transmission. — That the disease may be transmitted from those 
affected to the well has never been proved, and it cannot positively be 
placed in the communicable class, although such action has been taken 
by the New York Health Department. It is extremely rare for two 
cases to develop in the same family, even when no quarantine is estab- 
lished. I have seen many patients admitted to hospital wards contain- 
ing other children, and have never known a new case to develop under 
such conditions. Epidemics occur at different times in different lo- 
calities without assignable cause. Several children become ill in a 
given locality, covering perhaps a period of two or three months, and 
then the disease disappears. 

Various theories have been advanced from time to time as to the 



CEREBROSPINAL MENINGITIS 559 

mode of entrance of the meningococcus into the body. All the cases 
in a given epidemic are evidently infected from the same source. 
One of the means of infection is probably through the inspired air. 
The meningococcus has been found by different observers, as men- 
tioned above, in the mucous membrane of the nose. 

Age. — The disease is one of childhood. It may occur in earliest 
infancy, however, or in extreme old age. From two to ten years ap- 
pears to be the most susceptible age. Rotch had a patient six days old. 
Koplik's youngest patient was four months of age. 

Symptoms. — In common with all diseases in which the infecting 
agent is microbic in character, cerebrospinal meningitis may exist in 
so mild a form that it is not suspected, or it may be sufficiently severe 
to take the life of the child in a few hours. 

Illustrative Cases. — During the epidemic of 1904 and 1905 in New York city, I 
showed two patients — one a child of nine months, and one a child of four years of 
age — to my students at the New York Polyclinic Medical School and Hospital. 
In neither child could the men on the benches discover anything wrong. In the 
younger child the only symptom was a rather full fontanel and a tendency to 
drowsiness when left alone. At that time his cerebrospinal fluid contained the 
meningococcus. The four-year-old child had headache and some photophobia, 
and was extremely irritable. There had been vomiting, and there was an irregu- 
larity in the heart action. This boy sat up, answered questions, and did not appear 
at all ill. The day previous, meningococcus had been found in the cerebrospinal 
fluid. Both children recovered without treatment. 

Fulminating Cases. — On the other hand, during the same epidemic 
a girl of eight years was taken ill with the disease in the early morning 
and died about 10 o'clock at night on the same day. This very severe 
form is usually found among the earlier cases in an epidemic. The 
symptoms of these fulminating cases are from the onset most severe. 
The child is literally ''struck down. " The earliest symptom may be a 
violent chill, followed by fever, or the initial symptom may be a con- 
vulsion. If there is a convulsion at this period, the child rarely comes 
completely out of it. Active vomiting may be present. Extreme irrit- 
ability usually precedes the comatose state, which rapidly supervenes. 
Whatever may be the early manifestations in any fulminating case, 
two symptoms will always be present — intense headache and high 
fever. The heart action becomes very rapid, breathing is superficial 
and irregular, the pupils show no response to light, and the child can- 
not be roused. Rigidity of the neck muscles and general muscle 
contractions may be present. There is intense hyperesthesia, the 
slightest sound or touch being acutely felt and resisted. I have seen 
the child throw himself about during the first hours so that he was 
with difficulty kept in bed. 

Petechise appear, and ecchymotic areas soon are scattered over the 
surface. This symptom, however, does not occur in all cases. Exten- 
sive hemorrhagic purpura is of occasional occurrence in cerebro- 
spinal meningitis. I have seen two such cases in which large areas 
of the body surface were involved in subcutaneous hemorrhage. 
It is peculiar that in these cases the nervous manifestations were 



560 THE PRACTICE OF PEDIATRICS 

much less pronounced than in the average case. Diagnosis was proven 
by the typical findings in the cerebro-spinal fluid. 

Between the mild and fulminating types of the disease symptoms of 
any degree may exist, indicating the varying degrees of virulency of the 
infection. As a rule, the onset is more abrupt than in other forms of 
meningitis. Headache is a fairly constant symptom in all cases. This 
will be evidenced by complaint on the part of the child or in younger 
children by head-rolHng, or head-boring, or striking the head with the 
hands. 

Position of Patient. — The position of the child when the case is fully 
developed is characteristic. The patient rests on his side; the head is 
retracted, the knees are drawn up, and the legs are flexed on the thighs; 
the arms are flexed and the hands clinched. 

The Fontanel. — The distention of the fontanel in the younger 
patients is a constant and very reliable sign. 

The Temperature. — The temperature is variable and irregular — now 
high, now low; there is no characteristic temperature range in the disease. 

Convulsions occur in a majority of the cases. There is always hy- 
peresthesia, and evidence of much discomfort when the child is handled. 

Muscle rigidity is usually present, even in the milder cases. The 
entire body may be involved and become stiff and rigid, or a muscle 
group only may be involved. Rigidity of the neck and some degree 
of opisthotonos are rarely absent, except in the milder cases. The 
feet are held in a position of extension. Swallowing is difficult or im- 
possible, and toward the end, in fatal cases, gavage has to be resorted 
to. In the recovery cases, also, during the active stages of the disease, 
this measure may be necessary to sustain the patient. 

Heart and Respiration. — The heart action is much disturbed. It 
may be very rapid or slow. The usual condition is that of slowness 
and irregularity. 

The respiration likewise is slow and irregular, and may assume the 
Cheyne-Stokes type. 

Mental Apathy. — The child becomes extremely dull, and is aroused 
with difficulty. From this condition he may recover, or, what is more 
frequently the case, he passes into a condition of stupor and coma. 

Bowel Conditions. — The bowels are usually constipated and the ab- 
domen is retracted. These symptoms, made much of by writers, are 
very variable and may or may not be present in severe cases. 

The Eyes. — The eyes frequently show strabismus. The pupils are 
usually dilated, often unequal in size, and show no response to light, 
or react but slowly. 

The Ears. — Deafness may occur early and continue throughout. 
In the absence of local ear changes it is due to an inflammatory in- 
volvement of the auditory nerve. 

The Skin. — In but a few cases seen by me have there been skin 
changes. Petechiae and ecchymoses have been seen in the very malig- 
nant forms. The skin in the mild and moderately severe cases has 
remained negative. 



CEREBROSPINAL MENINGITIS 561 

Symptoms in Recovery Cases. — In a case in which there has been 
a moderately severe infection and which goes on to recovery, there is 
a train of symptoms which indicates the favorable outcome. 

As might be expected, a general clearing of the dulled mentahty is 
one of the earliest and most favorable signs. The temperature, which, 
though variable as to degree, is almost always present, subsides. The 
child evidences a desire for food, and makes attempts at using his stiff- 
ened muscles. Muscle rigidity is the last symptom to disappear. I 
have repeatedly known children to talk, to play, and be interested in 
their surroundings; in fact, apparently well, with the exception of the 
muscle contraction which held them in the characteristic position of 
opisthotonos. 

Illustrative Case. — A child seen at various times in consultation with a colleague 
was blind for six weeks, absolutely deaf for three months, and on his back for five 
months, yet made a perfect recovery. Toward the end he was emaciated to a skele- 
ton. I saw the boy on three occasions, and each time made a fatal prognosis. 
Four months after my last fatal prognosis I saw the boy on the street playing with 
other boys. 

Diagnosis. — Abrupt onset is the rule. Convulsion, vomiting with- 
out apparent cause, chill, headache, more or less intense photophobia, 
hyperesthesia, rigidity of the neck muscles, and fever constitute the 
earliest diagnostic signs. Such a symptom-complex, followed by 
drowsiness and stupor, warrants the use of lumbar puncture (p. 566) 
to determine positively the presence of meningitis. This should be 
done in all suspected cases so as to give the patient the benefit of the 
Flexner serum at the earliest possible moment. The later manifesta- 
tions of the disease are unmistakable. The rigid neck, opisthotonos, the 
dilated, unequal and immobile pupils, the slow, irregular respiration, 
and slow, irregular pulse, comprise a group of diagnostic signs found 
only in meningitis. 

Hyperesthesia is always present. The child almost invariably 
cries when disturbed or handled in any way, while his mentality is still 
able to appreciate the disturbance. 

Kernig's Sign. — This consists in an inability to extend the leg on 
the thigh when the latter is flexed on the abdomen. The sign is present 
and is fairly reliable in children over two and one-half years of age. 
In younger children, particularly those under eighteen months, because 
of the normal tendency to contraction of the flexor muscles at this 
period of life, the sign is of less value. 

Kernig's sign is also present in other cerebral lesions and in other 
forms of meningitis. 

Bahinski^s phenomenon consists in an extension of the great toe 
and a flexion and separation of the remaining toes when the plantar 
surface of the foot is stroked with the finger. This sign is often absent, 
and is of corroborative value only in the event of other symptoms. 
Its presence may be an indication of meningitis, and its absence is of 
no significance. I have produced this reflex repeatedly in normal chil- 
dren under eighteen months of age. 

The tache cerebrale may be demonstrated in practically every case. 
36 



562 THE PRACTICE OF PEDIATRICS 

The patellar reflex is variable and uncertain. It may be increased, 
diminished, or absent, and is of Httle diagnostic value. 

The Eye Changes. — The pupils are usually dilated, often unequal, 
and may show no response to light or react slowly. 

Strabismus is always present at some stage. The eye-grounds may 
show retinitis, choroiditis, or neuritis of the optic -disk. In the pro- 
longed cases conjunctivitis and keratitis are often present. 

Heart Action. — The pulse is slow and irregular. It may be inter- 
mittent, or now and then a case will be seen in which the pulse is very 
rapid — ^160 to 200 — with a normal temperature. 

The respiration is likewise disturbed, slow, and of the Cheyne- 
Stokes type. The respiration is very changeable at an examination, 
the rate being now slow and irregular, now very rapid. 

The temperature range is in no way diagnostic, although tempera- 
ture is usually present. 

Emaciation. — There is such a marked loss in weight that the emacia- 
tion may be looked upon as one of the symptoms of the disease. In 
all cases there is wasting, and the longer the case, the greater is the 
emaciation. 

A ward filled with these emaciated children, with their dulled, star- 
ing eyes and bent, rigid trunks and limbs, furnishes a most pitiful and 
gruesome picture. 

Differential Diagnosis. — In spite of the foregoing signs and symp- 
toms we have cases of cerebro-spinal meningitis which may only be 
differentiated from other types by an examination of the spinal fluid. 

Complications. — Considering the nature and severity of its symp- 
toms, cerebrospinal meningitis is a disease with few complications. 
Pneumonia is only an unusual occurrence. Eye involvement is to be 
looked upon more as a feature of the disease than as a complication. 
Nephritis is exceedingly rare. Bed-sores are frequently developed, and 
become a troublesome feature, but again this cannot properly be con- 
sidered a complication. 

Among the sequelae are idiocy, blindness, deafness, epilepsy, acute 
and chronic hydrocephalus, and spastic paralysis of different sets of 
muscles. I have several patients under my care who have survived 
meningitis and are considered to have had complete recoveries, who 
are, nevertheless, backward in school, have severe headaches, or who 
show marked absence of control. 

Duration. — The duration of the disease depends largely upon the 
nature of the infection. Death may take place in a few hours, or the 
patient may linger for weeks. A boy twelve years of age, whom I 
cared for several years ago, died from exhaustion in the twentieth 
week of the disease. I have repeatedly seen children make partial re- 
coveries and linger for several weeks in a wretched, emaciated condition 
and eventually die from asthenia. Others make incomplete recoveries 
which place them in the dependent class for the remainder of their lives. 

Treatment of Cerebrospinal Meningitis. — The medication and 
general management in cerebrospinal meningitis are the same as 



CEREBROSPINAL MENINGITIS 



563 



suggested for acute infective meningitis (p. 551). Little or nothing is 
to be expected from drugs, except such as may be used for palUative or 
laxative purposes. 

Serum Treatment. — The Flexner serum is the only means of treat- 
ment at our command which promises any curative effects in the dis- 
ease. In 1904 Flexner produced an anti-meningitic serum for the treat- 
ment of cerebro-spinal meningitis. Horses were immunized by graded 
injections of cultures of the diplococcus intracellularis and its toxin. 
He distributed this serum to many observers throughout the world and 
in 1913 made a final report of 1294 cases which had been treated with 
this serum, which is injected intraspinally. The effect of the serum 
is partly bactericidal, partly by bringing about phagocytosis and 
probably partly by an antitoxic reaction. Previous to the use of the 
serum the mortality ranged from 50 per cent, to 90 per cent. ; since its 
use the mortality has been reduced from 20 per cent, to 30 per cent. 
The following are the statistics of results as compiled by Flexner.* 



MORTALITY ACCORDING TO AGE 




Age 


Cases Recoveries 


Deaths 


Mortality 


Under 1 year. 


129 

87 
194 
218 
360 
288 

18 
1294 


65 

60 

139 

185 
254 
180 
11 
894 


64 

27 

55 

33 

106 

108 

7 

400 


49 6 


Between 1 and 2 years 

Between 2 and 5 years 

Between 5 and 10 years 

Between 10 and 20 years. . . . 
Over 20 years 


31.0 
28.4 
15.1 
29.4 
37.5 


Age not given 

Total 


38.9 
30.9 



MORTALITY ACCORDING TO PERIOD OF 


FIRST INJECTION 


Period of Injection 


Cases 


Recoveries 


1 

Deaths j Mortality 


1st to 3d day. 


199 

346 

666 

1211 


163 

252 
423 

838 


36 
94 

243 
373 


18 1 


4th to 7th day 


27 2 


Later than 7th day 

Total 


36.5 
30.8 



The average mortality rate of the patients of 19 observers who have 
published their results in the literature was 29 per cent. This com- 
pilation totals 4664 cases with 1338 deaths. 

The use of serum gives the best results when injected early and in 
children between the ages of 5 and 10 years. The serum is useful, how- 
ever, even if injected late in the disease. Infants under one year do not 
respond readily to the serum. With the use of the serum 30 per cent. 
of the favorable cases terminate abruptly, while without serum crises 
are unusual. When the first injection is made within the first three 
days, 50 per cent, terminate by crisis. There has also been a re- 

* Journal Exp. Medicine, May, 1913. 



564 THE PRACTICE OF PEDIATRICS 

markable reduction in the severity and number of complications by 
the use of serum. Out of 894 children in Flexner's series who re- 
covered, 68 or 7J^ per cent, had complications as follows: 



39 cases 


Total deafness 


4.4 per cent. 


6 cases 


Partial deafness 


0.7 per cent. 


3 cases 


Total blindness 


0.3 per cent. 


6 cases 


Partial blindness 


0.7 per cent. 


3 cases 


Impaired mentality 


0.3 per cent. 


11 cases 


Paralysis 


1 per cent. 



There have been some noteworthy improvements made in the serum 
since it was first produced. Many children were found who did not 
react favorably. Investigations proved that there are many strains of 
the meningococcus; notable among these is the parameningococcus. 
Horses used to supply the serum are now injected with the cultures of 
these different strains. 

Because of the prevalence of the disease among the soldiers at the 
front on the continent, it was found necessary to hasten the production. 
Wollstein and Amoss* have perfected a method by which the serum can 
be produced in 8 to 12 weeks instead of 6 to 12 months as heretofore. 

Method of Use. — The first injection of serum is given in a suspected 
case as soon as turbid fluid is withdrawn; without waiting for bacterio- 
logical examination. It is best to withdraw all the fluid possible at 
each puncture and then inject 25 to 35 c.c. of serum by the gravity 
method. One injection rarely suffices. Four injections given daily 
is the average, but some patients require as many as twelve. In the 
very severe cases the second injection should follow in twelve hours. 
Even though an injection does not seem necessary a puncture should 
be done every day or two during the course of the disease for bacterio- 
logical examination. The most important indication for an injection 
is the clinical aspect of the patient. Even though the fluid becomes 
clear and no diplococci are found, if there is persistent Kernig's sign, 
iregularity of temperature or mental symptoms, a repetition of the 
injections is necessary. 

Soon after one or two injections of the serum in favorable cases, the 
diplococci in smears are greatlj^ reduced in number, become intracellu- 
lar, and finally disappear. The organisms should also present changes 
in appearance, as swelling and fragmentation, stain diffusely and in- 
distinctly and lose their mobility in cultures. The purulent appear- 
ance of the spinal fluid becomes more translucent and finally clears. A 
reduction of the leukocytes in the blood follows if the serum is success- 
fully combating the disease. 

Technic of Serum Injection. — The patient is placed in the 
usual recumbent position for spinal puncture. If an infant, and 
can be properly held by an assistant, no anesthetic is necessary. 
Chloroform had best be administered to the older children who 
resist holding. The gravity- method is preferable to the syringe. 
Sophian of New York has perfected a blood pressure control 

* Journal of Exp. Med., May, 1916. 



MENINGISMUS (SEROUS MENINGITIS) 565 

for the withdrawal of fluid and the injection of serum. When the spinal 
fluid is being withdrawn there should be a drop of not more than 5 to 10 
mm. of mercury. In case of a further drop no more fluid is removed. 
The funnel of the apparatus is filled with serum which has been heated 
to body temperature. All air should be carefully eliminated from the 
connecting tube. The funnel is gradually raised to permit the serum to 
flow in gradually by gravity. It is seldom possible to inject as much 
serum as fluid withdrawn without disconcerting symptoms. If the 
blood pressure drops 10 mm. of mercury the process should be tem- 
porarily discontinued until the normal blood pressure is restored, at 
least in part. Where the pressure continues to fall, discontinue the 
injection. It is always a wise precaution to keep the tube connected 
for three minutes after the injection, so that the serum may be with- 
drawn by lowering the tube if the child shows a falling pressure, dilata- 
tion of the pupils or shallow irregular respirations. If these symptoms 
supervene, the head should be raised and injections of atropin and 
adrenalin administered intramuscularly. 

The spinal fluid in some cases will become clear and show very few 
meningococci and yet the fever and prostration continue. This is due 
to adhesions or thick exudate at the base of the brain which does not 
allow the serum to reach the meninges or the lateral ventricles. When 
this occurs it is necessary to puncture the ventricle through the an- 
terior fontanelle, withdraw the fluid and inject the serum. In older 
children, trephining may be necessary. Another not unusual obstacle 
to the treatment with serum is a very thick gelatinous fluid which is 
withdrawn with difficulty. In such cases Sophian recommends care- 
ful irrigation with normal saline to aid the withdrawal of the fluid. 

Vaccines. — The first cultures obtained are used for the preparation 
of an autogenous vaccine. This is used if the case takes a chronic 
course. Subcutaneous injections on alternate days ranging from 200 
million to 2000 million are given, increasing by 200 million at each 
injection. As many as 10 injections are given if necessary 

MENINGISMUS (SEROUS MENINGITIS) 

Meningismus is a term first employed by Dupre to describe cere- 
bral intoxication, a condition clinically closely resembling meningitis, 
in which the spinal fluid is sterile. This condition may occur in any 
very severe illness of infancy or childhood. It may occur in typhoid, 
acidosis, acute gastro-enteric intoxication, influenza, pneumonia or any 
of the exanthemata. Very severe scarlet fever is apt to be accom- 
panied by meningismus. 

Symptoms. — There may be stupor, coma or convulsions, retraction 
of the head, vomiting and twitchings of the face or various parts of the 
body. In fact the symptoms so closely resemble true meningitis and 
acute polio-encephalitis that a differentiation is only possible in some 
instances by means of the lumbar puncture. 

Diagnosis and Differential Diagnosis. — In true meningitis, whether 
simple, acute cerebrospinal or tubercular, microorganisms are present 



566 



THE PRACTICE OF PEDIATRICS 



in the cerebrospinal fluid, the cell count is increased and globulin is 
usually present. The pupils may be dilated or contracted and show 
slow response to light, but in meningismus they act together and 
evenly. I have never seen the symptom of absence of coordination of 
the pupils that was not true meningitis. The eye-ground changes 
in meningismus are negligible. 




Fig. 75. — Position for and site of lumbar puncture. 

Further it is to be remembered that in meningism^us there is usually 
the association of other diseases, and the cerebral signs are secondary. 

Lumbar Puncture. — In any case showing active cerebral symptoms, 
a lumbar puncture should always be made. 

Treatment. — The treatment is covered in the management of the 
disease with which the meningismus is associated. 

LUMBAR PUNCTURE 

The site selected for lumbar puncture is on a line between the crests 
of the ilia and between the spinous processes of the third and fourth 
lumbar vertebrae. 




-Quincke's needle. 

Position of the Patient. — The child should rest on one side (see Fig. 
75) , sufficient pressure being exerted on the buttocks to make the spin- 
ous processes prominent. The Quincke needle (Fig. 76) should al- 
ways be used in making the puncture. The stylet which fits the 
beveled edge of the point of the needle effectually prevents its being 
plugged. 

Method. — The skin for several inches about the site of the puncture 



LUMBAR PUNCTURE 567 

should be scrubbed with the tincture of green soap and alcohol. The 
physician's hands should be thoroughly disinfected. Considerable 
force may be necessary in order to enter the canal. When there is a 
sudden giving way of the obstruction to the progress of the needle, one 
may know that the canal has been entered. The puncture may be 
made in a line with the spinous processes or from the side, the needle 
being passed between the laminae and inward about one inch. When 
the point of the needle has been introduced into the spinal canal, the 
stylet is withdrawn. The cerebrospinal fluid may escape with force in 
a stream as a result of the pressure or it may exude drop by drop. A 
sterile tube should be in readiness in order to collect the fluid for ex- 
amination. In dealing with older children after the third year it is 
often easier to introduce the needle slightly to the right or left of the 
line of the spinous process. 

When the canal is entered and the cerebrospinal fluid does not pass 
readily through the needle, the flow may be increased by elevating the 
child almost into a sitting position with the head forward. A dry tap 
usually means that the canal has not been entered. For some children 
it will be necessary to employ a slight degree of anesthesia. I have 
used both gas and chloroform for this purpose. 

Uses of the Lumbar Puncture. — The uses of lumbar puncture are 
threefold: for diagnostic purposes; as a means of conveyance of sera 
to the spinal canal, and for the relief of acute symptoms by the with- 
drawal of the fluid, thereby relieving pressure. 



XIV. DISEASES OF THE SKIN 

The skin of an infant is to be looked upon as an organ with impor- 
tant functions to perform. On account of its location it is the most 
exposed organ of the body; among its most important functions is, 
therefore, protection of the underlying structures. 

In the skin, moreover, are located the most important organs of 
excretion, the sweat-glands, as well as those very delicate nerve struc- 
tures, the tactile organs. Through the skin, heat radiation is carried 
on by means of the circulating blood in the capillaries. When we con- 
sider the active metabolic processes that are taking place in the infant 's 
body, it is not hard to appreciate the amount of work the skin is called 
upon to do in performing its functions of excretion and heat radiation. 

Care of Skin in Health. — The skin in the infant is particularly deh- 
cate, and responds very readily to external irritation of any nature. 
Excessive clothing at any time of the year, but more particularly in 
summer, produces the well-known prickly heat or sudamina. Eczema 
may result from the irritant effects of improper clothing. 

The different forms of intertrigo are the result of irritation produced 
by the contact of unclean napkins containing urine or feces or both. 
In order to avoid intertrigo the napkin must be changed during the 
waking hours whenever the urine is voided. In some instances it is not 
well to wake a child for a change of napkin because of urination ; and 
at other times during the day, such as the outing period, the clothing 
cannot always be changed in the park or street. Under such circum- 
stances a prophylatic measure should be employed. Over the groin 
and folds of the buttocks should be spread pieces of old linen which have 
been well smeared with the following ointment : 

I^ Cerse albse 3iv 

Ungt. zinci oxidi q. s. ad §iv 

The addition of white wax to zinc oxid ointment acts as a water- 
proof dressing to the skin, and protects it from the irritating products 
of decomposing urine. 

Clothing that is applied too tightly will act as an irritant to many 
skins. To many wool acts as a decided irritant, and frequently it must 
be avoided. In some instances it has been necessary to line the child 's 
undergarments with thin old linen, such as a handkerchief. Linen 
mesh underclothing may be used. 

In order further to keep the skin healthy, the child should be bathed 
in a tub once a day with Castile soap, then carefully dried, and pow- 
dered with a simple powder. 

568 



I 



MILIARIA 569 

The following powder I have used extensively for years: 

I^ Acidi borici gr. xxv 

Pulv. amyli, 

Pulv. zinci oxidi aa§ss 

M. Sig. — Apply freely. 

I prefer the evening bath. In the morning the child is sponged with 
warm water and soap and carefully dried, after which the powder is 
applied. During the cold weather the bathing and sponging should 
be done in a warm room with a temperature over 75°F. 

The above simple means are all that are necessary to keep the skin 
in a normal condition. The skin of some children is much more sensi- 
tive than that of others, and will require more careful attention. 

MILIARIA (PRICKLY HEAT) 

The rash in prickly heat consists of multiple, minute, transparent 
vesicles, due to an engorgement of the vessels of the sweat-glands and 
obstruction of their outlets. 

Symptoms. — The child is very uncomfortable and restless. The 
itching is evidently very distressing. The rash described is character- 
istic, and usually appears quite suddenly. The mild cases are without 
inflammation. The inflammation, when present, produces a general 
erythema with many reddened papules. 

Etiology. — Nearly every infant in our climate suffers from prickly 
heat during the summer. The condition in summer is caused by pro- 
fuse sweating, incident upon the hot weather and independent of pos- 
sible overclothing; in winter, by too hot living rooms and overclothing. 

Treatment. — Heavy clothing and flannels are to be avoided. In 
order to lessen the local irritation, the garment worn next to the skin 
should be lined with silk or linen, or linen mesh garments should be 
worn. The further management directed both to the relief of the pa- 
tient and the cure of the condition consists in the frequent application of 
cool water, either by means of a tub-bath or sponging. The soda 
bath, the bran bath, and the starch bath (p. 780) are all most useful. 
For purposes of sponging a solution of bicarbonate of soda should be 
used — -one tablespoonful to a gallon of water The relief afforded the 
patient depends not so much upon what is used in the water, as upon 
the fact that plenty of cool water comes in contact with the itching, 
burning skin. Ointments and salves are here of little service, as they 
tend to produce further maceration of the skin. As local applications, 
powders are to be preferred to lotions. A powder used with satis- 
faction for this condition is of the following composition: 

I^ Acidi salicylici gr. x 

Acidi borici gr. Ix 

Pulv. amyli, 

Pulv. zinci oxidi aa § j 

This is to be dusted freely over the involved surface several times daily 
— every hour if necessary. In case irritation is produced by the sali- 
cylic acid, it may be omitted or its strength may be decreased by the 
addition of powdered starch. 



570 THE PRACTICE OF PEDIATRICS 

URTICARIA (HIVES; NETTLE-RASH) 

A discussion of all the aspects of urticara is unnecessary. Only 
those forms will be considered which are peculiar to children. 

Acute urticaria is characterized by the sudden appearance and dis- 
appearance upon the skin surface of wheals and lumps of vasomotor 
origin. The wheals, which are of varying size, produce intense itching 
and burning, and then subside without desquamation as rapidly as 
they have appeared. The variation in size and shape has given rise to 
a differentiation into types for purposes of diagnosis. 

Distribution. — The possibilities of skin involvement in hives are 
most variable. There may be but one wheal, or the lesions may cover 
a large portion of the skin surface. The involved area may be very 
small, of the size of a pin-head, or extremely large (giant hives, below) , 
occasionally producing marked facial deformity. Thus in the case of a 
child of eleven months who had been given an egg for the first time the 
face was so distorted and grotesque that recognition was impossible. 

Etiology. — ^Urticaria may be due to agencies operating either from 
without or within the body. Those operating from without include 
irritants of almost any nature, especially the bites of insects, and too 
tight clothing or clothing which may directly irritate the skin. Contact 
with certain plants may also produce the wheal hives, termed '^nettle- 
rash." Such causes as these, however, are operative in comparatively 
few cases. 

Irritation arising from internal sources is the cause of the condition 
in at least 95 per cent, of the cases. The use of certain drugs may oc- 
casion sufficient irritation to cause an outbreak. In not a few instances 
I have seen hives due to quinin, arsenic, and antipyrin. The adminis- 
tration of antitoxin produces hives in from 15 to 20 per cent, of the cases. 
Certain articles of food, such as strawberries, tomatoes, oatmeal, and 
buckwheat, invariably cause urticaria in some children. An attack 
may occur without apparent digestive disturbance, or may appear 
coincident with vomiting, diarrhea, fever, and other acute gastro-in- 
testinal symptoms. The condition is due to a toxin from alimentary 
sources which produces vasomotor disturbances of the skin blood- 
supply, resulting in localized vascular paralysis and transudation. 
The itching is due to irritation of the nerve end-organs. 

Giant Hives (Angioneurotic Edema). — This condition is of com- 
paratively rare occurrence in children. I have seen but a few cases. 
It is simply a variety of urticaria occasioned by causes similar to those 
operative in other forms. When it occurs in children, it most frequently 
involves the tongue and lip. When involving the soft parts, the 
lesion may produce an immense amount of swelling. This is particu- 
larly marked when the tongue and lips are affected. I have seen the 
lips swollen to several times their normal thickness. In a boy four 
years of age the tongue and lower lip were so greatly swollen that 
speaking was impossible and swallowing difficult, and it was supposed 
that he had been given carbolic acid or some corrosive poison. Such 
cases usually develop suddenly and occasion no little alarm. In the 



RHUS POISONING (iVY POISONING) 571 

case referred to I was called 30 miles into the country to see the child 
in consultation. Cases have been reported in which the swelling of 
the tongue was sufficient to produce suffocation requiring incision to 
reduce the swelling. 

The cases seen by me have all been associated with gastro-intestinal 
-disturbances. The swellings ordinarily disappear rapidly after a few 
hours, but not with the rapidity which marks their initial appearance. 

Treatment. — Digestive disturbances of any nature, whether acute 
or chronic, may cause urticaria. In the event of an attack, therefore, 
even though there be no active manifestations of indigestion, the origin 
of the trouble will usually be found in the intestine. A safe procedure 
is to give two to four teaspoonfuls of castor oil, or 1 J^ grains of calomel 
in divided doses, followed the next morning by the citrate or milk of 
magnesia. At the same time the diet, regardless of the age, should be 
Teduced to broths and gruels, to which toast or dried bread may be 
.added, depending on the patient's custom. Milk should not be given. 
The application of a menthol ointment (menthol, 10 grains; rose-water 
ointment, 1 ounce) is a valuable supplementary measure. 

In cases caused by antitoxin and food allergy, salicylate of soda 
(wintergreen) will effect a termination of the symptoms sooner than will 
any other agent. To a child three years of age 2 grains of the salicylate 
of soda may be given every two hours, with 4 grains of the bicarbonate 
of soda — 5 doses being given in twenty-four hours. To older patients 
from 3 to 4 grains of the salicylate may be given at a dose — from 12 to 
24 grains being administered in twenty-four hours. Certain children 
appear to be predisposed to urticaria, and give a history of having had 
several attacks. Those who suffer from persistent intestinal indigestion 
are very liable to recurrent attacks, which are sometimes very obstinate 
in character. Urticaria due to the ingestion of a drug will disappear 
when the drug is withdrawn. 

The management of the cases due to local causes demands the re- 
moval of the source of the irritation and the application of the menthol 
ointment, or bathing of the affected part with a 1 per cent, carbolic 
:acid solution. 

RHUS POISONING (IVY POISONING) 

Contact with the Rhus toxicodendron produces in many people a 
most active dermatitis, characterized by marked burning and consider- 
able itching of the involved surface. There may be a simple erythema 
but usually there are small vesicles and bullae filled with serum, which, 
if they become infected, form pustules, with the possibility of multiple 
abscesses. The exposed portions of the body — the hands, arms, face 
and neck — are the most frequently affected sites. When the face is 
involved, great disfigurement may result. 

Treatment. — I have used various measures from time to time in the 
treatment of this form of dermatitis. For the acute stage — the period 
of itching, burning, and edema — a remedy of considerable value is a 
-wet dressing of the fluidextract of Grindelia rohusta, 1 to l}'^ drams to 



572 THE PRACTICE OF PEDIATRICS 

the pint of water, applied on lint or soft old linen. The solution should 
be used cold and renewed every fifteen to thirty minutes. During the 
stage of resolution a saturated solution of boric acid may be used in the 
same way, or, more conveniently, an ointment composed of 5 per cent, 
boric acid in rose-water ointment. This is applied to the parts on linen, 
after which resolution usually promptly takes place. When pustules 
develop, they must be opened and the parts treated with a wet dress- 
ing of a saturated solution of boric acid. 

A solution of permanganate of potash, 1 : 2000, is a most satis- 
factory means of treatment. The involved parts are freely moistened 
with the solution at intervals of about two hours, the solution mean- 
time being allowed to dry on the parts. This often readily controls 
the acute symptoms. After a few days a 10 per cent, boric-acid oint- 
ment may be used to soften the skin and remove the crusts and prod- 
ucts of the exudation. 

SCABIES (ITCH) 

Scabies is a contagious disease of the skin, caused by the burrowing 
of the female itch-mite, Acarus scabiei. 

Location. — The parts selected for invasion are those portions of 
the skin which are least protected and least resistant, the favored sites 
being between the fingers and toes, in the axilla, and in the groin. The 
skin over the trunk is usually invaded secondarily. 

The impregnated female burrows a tunnel into the layers of the skin, 
which serves as a habitat for the mite during her life. 

In the burrow or canal are deposited the eggs, larvae, and excre- 
tions of the acarus, and these act as an irritant, producing papules, 
vesicles, and skin infiltration. The presence of the parasite and its 
products causes intense itching which, through scratching, indirectly 
adds to the existing skin irritation. If the skin is clean, the burrows 
may be seen with the aid of a magnifying glass. Upon removal of the 
epidermis at the end of the canal the parasite may be removed with a 
needle. 

Diagnosis. — Itching is intense and may be confined to the skin areas 
described, or involve all portions of the skin surface. A point of diag- 
nostic value is that the itching is much worse at night due to the fact 
that the mite evidently becomes more active as a result of the increased 
warmth and quiet supplied by the unwilling host. 

In a well-marked case as a result of the action of the acarus together 
with the trauma produced by scratching there is a complex skin 
picture very difficult to describe. An eczema with all its possibilities 
of skin inflammation and infection usually supervenes. The burrows 
have the appearance of dark colored lines extending in a tortuous, 
zigzag course rarely exceeding 3^^ inch in length, and these are usually 
visible in sufficient number to make the diagnosis positive. 

Treatment. — The cases differ in severity, but in all the treat- 
ment is practically the same, varying only in respect to the necessity 
of its repetition or continuation. At bedtime a hot bath is ordered, 



FTJRUNCULOSIS (bOILS) 573 

from 105°F. to 110°F. While in the bath the patient is vigorously 
scrubbed with a towel and yellow laundry soap. After the scrubbing 
he is dried vigorously and sulphur ointment, U. S. P., rubbed as 
vigorously into the skin. This process is repeated twice at intervals 
of forty-eight hours. The repetition at twenty-four-hour intervals 
is usually too irritating to the skin. The third treatment usually ter- 
minates the case. For quite young children, to whom the sulphur 
ointment may be too irritating, and for older children also if the first 
application produces considerabe dermatitis, the ointment may be 
diluted one-fourth or one-half by the addition of vaselin. Care must be 
exercised to destroy, boil, or otherwise disinfect.all clothing previously 
worn by the patient. 

FURUNCULOSIS (BOILS) 

Boils are frequent in delicate, poorly nourished infants and children, 
and are due to an inoculation of the deep layers of the skin with the 
staphylococcus. Boils may develop in well babies, even under proper 
management, for many delicate skins possess a very poor resistance to 
the staphylococcus. Often there will be a crop or two comprising per- 
haps not over five or six lesions in all. In marasmic infants and poorly 
nourished young children, however, the lesions may occur in great 
number. I have opened over one hundred furuncles in one patient in 
caring for the successive crops as they appeared. The scalp is appar- 
ently the most fertile field for their development. I have repeatedly 
seen the boils coalesce, forming a large, sloughing suppurating mass. 
In aggravated cases, in delicate infants with low resistance, fatal results 
are not unusual in institutional work. What might be looked upon as 
a chronic condition of furunculosis sometimes exists in older children. 
The boils will continue to appear at indefinite intervals for a year or 
more in spite of active vaccine treatment. 

Treatment. — Local. — When pus is evident in the boil, a free in- 
cision should be made and the pus expressed. The skin about the 
wound should be washed vigorously with tincture of green soap or 
ordinary soap and water. Applying a few drops of a solution of 
bichlorid of mercury is of little or no value, and will not be sufficient to 
prevent a reinfection, as some pus invariably escapes upon the surround- 
ing healthy skin when many boils are opened. A wet disinfectant 
dressing or a disinfectant ointment should follow incision and cleans- 
ing. Bichlorid dressings are to be used only temporarily in children. 
The dressing which has appeared best to prevent the spread of the in- 
fection when the involved area is not too large is a saturated solution 
of boric acid, applied by means of gauze or lint. In a marantic child, 
when a considerable portion of the surface over the trunk or thorax 
needs to be covered the repeated renewal of the solution causes a 
reduction in temperature which is not desirable. In treating such 
infants, and in out-patient work where a wet dressing cannot be used, 
an ointment of 15 per cent, boric acid in vaselin is thickly spread on 
lint and applied to the wound and a considerable portion of the sur- 



574 THE PRACTICE OF PEDIATRICS 

rounding area. The dressing should be changed every six hours, 
Ichthyol is of Uttle service when used in a strength of less than 20 
per cent. The odor is disagreeable; the application stains the skin 
and the clothing and controls the condition no better than does the 
boric-acid ointment. Moreover, the latter is comparatively inex- 
pensive. In treating fat children who sometimes develop boils on the 
abraded surfaces at the folds of the neck or the nates, and children 
who perspire freely, I have used a dusting-powder composed as follows:: 

I^ Pulv. acidi borici §j 

Pulv. amyli, 

Pulv. zinci oxidi aagiss 

M. Sig. — Dusting-powder. 

This is applied as soon as the wound is closed, and the parts are 
thus kept dry. 

The autogenous vaccines have been most serviceable in the treat- 
ment of furunculosis in infants. (See Vaccine Therapy, p. 797.) 

Constitutional. — The constitutional treatment is important. If the 
child is marasmic or suffers from malnutrition, the general treatment 
suggested for these conditions should be brought into use. If delicate 
or anemic, the patient should have the advantage of the suggestions 
on p. 122. In the many cases which I have treated, internal medica- 
tion, other than that directed toward the improvement of the general 
constitutional condition, has been without value. The sulphid of cal-^ 
cium and other drugs which are supposed to have a direct influence 
upon the condition have proved of no service. They were not consid- 
ered valueless because the child did not recover, for if not too reduced 
in vitality, the patient always recovers, regardless of the treatment. 
Observation on a series of cases of this type, for which opportunity 
was afforded by institution work has shown that those treated with 
the sulphid of calcium, for example, made no greater progress than did 
those to whom it was not given. The existence of this line of treat- 
ment is an example of *' heredity in medicine.'* A remedy advocated 
by some one of consequence in the past is handed down from genera- 
tion to generation by writers, many of whom, not having had oppor- 
tunity to support their advocacy of the measure with observations of 
value, simply repeat what has been said by their predecessors. 

No matter how extensive the process, children with furunculosis 
may be bathed as in health. To the water for the bath, which should 
first be boiled, bicarbonate of soda, one tablespoonful to the gallon,, 
should be added. There should be little or no friction of the skin. 

PEDICULI (HEAD LICE) 

Head lice, pediculi capitis, constitute a very frequent source of 
annoyance in out-patient and hospital work among children. Occa- 
sionally children better situated may become infected in school or in 
public conveyances and carry the vermin to other members of the 
family. I have repeatedly known all the female members of a house- 
hold to become infected. 



TINEA CIRCINATA (rING-WORM) 575 

Symptoms. — As a result of the irritation produced by the insect 
and the enforced scratching, an eczema of the scalp is of frequent oc- 
currence. The eczema may be slight or give rise to a most extensive 
and disgusting condition. The suppurating scalp, matted with pus, 
crusts, nits, and vermin, supplies a picture disagreeable even to consider. 
In not a few instances I have seen the brows and eyelashes involved. 
A slight degree of postcervical adenitis is the rule in cases of some 
weeks' duration. 

Diagnosis. — The diagnosis does not depend upon finding the hve 
vermin. The louse cements its egg to the hair, and the presence of 
the ''nit'' is in itself diagnostic. 

Treatment. — The most successful and cleanly treatment consists in 
cutting the hair short. The head should then be washed with soap 
and water twice a day; and once daily after the drying, the scalp should 
be thoroughly moistened with the following solution : 

I^ Acidi acetici 5ij 

^theris sulphurici § iij 

Tincturse delphinii, 

Spirit! vini rectificati aa 5 iv 

Improvement will follow a few treatments. The pediculi will be 
killed and the nits may be removed with a fine-tooth comb. If the 
patient is a girl, it is not absolutely necessary to sacrifice the hair. It 
may be parted from various portions of the scalp and the solution ap- 
plied, without the previous washing. However, if the hair is not cut, 
a much longer time willl be required to effect a cure. 

TINEA CIRCINATA (RING-WORM) 

Tinea circinata, ring-worm of the body, is a highly contagious para- 
sitic skin infection. 

Etiology. — The disease is due to the trichophyton fungus, which is 
identical with that causing tinea tonsurans. The exposed skin surface, 
the neck, and hands are the sites most frequently involved. 

Domestic animals are subject to the disease. It is rare in cows and 
horses, but quite common in dogs and cats. Children are often in- 
fected from cats and dogs. 

Symptoms. — The disease usually makes its appearance in the form 
of a small, reddened, irregular-shaped area, which soon becomes circu- 
lar and is covered with a fine, scaly desquamation. The area is sharply 
defined and spreads through the development of fine papules around 
the border of the patch. As the process extends there is a paling and 
smoothing out of the surface in the middle of the patches, while the 
exterior border remains somewhat elevated and reddened. This pro- 
duces in the lesion a ring-form appearance which has given rise to the 
term by which it is known. There may be but one lesion or there may 
be dozens of varying sizes, J^ inch to 2 or more inches in diameter. 
Occasionally the smaller patches run together, forming large areas of 
irregular shape. 

Diagnosis. — The diagnosis is usually not difficult. The character- 



576 THE PRACTICE OF PEDIATRICS 

istic well-defined ring, circumscribed and usually multiple, is not simu- 
lated by other skin diseases. In some cases in which the margin is 
not so well defined, and in those which show one or more circumscribed 
scaly areas, the lesion may be confused with a patch of seborrheic 
eczema. Psoriasis may resemble ring-worm. Psoriasis is, however, 
very rare in children. Furthermore the lesions of psoriasis are usually 
located and grouped on the extensor surfaces and at the margin of the 
hair, and the scales are thicker and more abundant than those of ring- 
worm. In patches of acute eczema the characteristic abrupt margin 
is absent, itching is more marked than in ring-worm, and the inflam- 
matory manifestations are changeable from day to day, while in ring- 
worm the appearance of the lesion is without change. If doubt exists 
and the latter condition is present, a microscopic examination of the 
scales to which a few drops of liquor potassii have been added will re- 
veal the presence of the long, delicate threads of mycelium and thus 
settle the diagnosis. 

Treatment. — The treatment consists in the use of some irritant 
that will produce a desquamation of the superficial layers of the skin 
in which the fungus is located. The tincture of iodin has proved a 
satisfactory remedy whenever the lesion is located where its use is pos- 
sible. Two or three apphcations of the U. S. P. tincture at twenty- 
four-hour intervals constitute all the treatment ordinarily required. 
If the case proves obstinate, 2 grains of the bichlorid of mercury may 
be added to each ounce of tincture of iodin. If the lesion is situated 
on the face or elsewhere on the exposed surface of the body, 5 grains 
of bichlorid of mercury may be dissolved in equal parts of alcohol and 
glycerin, one ounce each, and applied locally three or four times daily 
until a slight dermatitis results. A rapid cure follows this treatment. 

TINEA TONSURANS (RING- WORM OF THE SCALP) 

Ring-worm of the scalp is of frequent occurrence in institutions for 
children, and is greatly dreaded because, when once it gets a foothold, 
it is most difficult to eradicate. In one epidemic of which I had charge 
there were over 100 cases. These cases were all cared for by nurses 
and orderlies who lived in the wards with the children and not one 
case occurred in an adult. The susceptible age appears to be from the 
third to the tenth year. 

Etiology. — Ring-worm is due to the action of the trichophyton fun- 
gus. The disease, which is most contagious, is transmitted by ex- 
change of caps, by means of towels, brushes, combs, etc. The dis- 
eased hair, according to Crocker, when placed under the microscope, 
after being soaked in B. P. liquor potassse for half an hour and gently 
pressed out under the cover-glass, presents the following appearance: 
The hair may be seen bent like a green stick, while the free end is frayed 
out like a brush, and (with a power of at least 200 or 300 diameters) 
abundant conidia or spores, with scanty mycehum, may be seen to 
permeate the shaft, both downward to the root end and upward above 
the surface for some distance, this appearance differentiating the con- 



TINEA TONSURANS 577 

dition from favus. Between the inner root-sheath and the shaft the 
conidia are also apparent in great numbers, but the mycehum is less 
abundant in the hairs than in the scales. The conidia measure from 
4 to 5 micra, and are round and sharply contoured, with a central 
nucleus like a black dot. The mycelium consists of well-defined, trans- 
parent, branched and pointed threads, terminating in conidia. They 
may be seen best in the .shaft near the bulb or between and on the 
scales. 

Diagnosis. — The diagnosis is not difficult. The circular circum- 
scribed patch with the short "stubbles" of hairs on the otherwise 
normal scalp is simulated by no other condition. The diameter of 
the involved area varies from J^^ inch to two or three inches. A large 
denuded area is usually the result of the coalescing of smaller areas. 
There may be but one involved area on a scale and there may be a 
dozen. 

Prophylaxis. — To prevent an epidemic when the disease breaks out 
in an institution which is the permanent home of children is most 
necessary and yet most difficult. The only means of stopping the 
spread of the disease, in my experience, has been in having the heads 
of all the unaffected children closely clipped and giving them a shampoo 
of equal parts of kerosene and olive oil twice weekly. 

Treatment. — Cures are difficult, and the treatment must be along 
radical lines. In an epidemic several years ago at the Country Branch 
of the New York Infant Asylum, abundant opportunity was offered 
to test the various measures of treatment advocated by different ob- 
servers. Among the applications used were chrysarobin in various 
combinations, carbolic acid, iodin, bichlorid of mercury, sulphur, and 
white precipitate. 

The location of the fungus in the hair-follicle renders it very diffi- 
cult to apply any drug so that it will be effective as a parasiticide. In 
order to accomplish this it is absolutely necessary to cut the hair of 
the entire scalp as short as possible. Upon beginning the treatment 
the scalp is thoroughly scrubbed with water and strongly alkahne 
yellow laundry soap, so as to remove all the dead hair and desquamated 
epithelium. The parasiticide to be used is then rubbed into the dis- 
eased area and for a considerable distance over the surrounding healthy 
scalp. The parasiticide which proved most valuable to us was com- 
posed of bichlorid of mercury, 2 grains in J^ ounce each of olive oil 
and kerosene. The bichlorid must be dissolved in a small quantity of 
alcohol before it is added to the oil mixture. This is rubbed into the 
diseased area every day until the scalp becomes sore and tender. In 
order to prevent the spread of the infection to other parts, the kerosene 
and olive oil without the bichlorid may be applied every fourth day, 
without friction, to the entire scalp. To effect a prompt cure it is 
necessary to produce a dermatitis at the site of the lesion. When this 
occurs, the treatment is temporarily discontinued. As soon, however, 
as the dermatitis subsides another inflammation is produced in like 
manner. After three or four weeks this treatment may be discon- 
37 



578 THE PRACTICE OF PEDIATRICS 

tinued while the patient is still kept under observation, in order ,that 
the physician may confirm the results. A daily application of sterile 
oil aids in bringing the skin to a normal condition. 

In treating one-third of the children in the epidemic referred to, 
2 grains of the bichlorid of mercury were added to 1 ounce of the tinc- 
ture of iodin. Twenty-six cases were treated by this method, with an 
average duration of treatment of eight and one-half weeks. Several 
recovered in four weeks, while for others twelve weeks of treatment 
were necessary. So long as the treatment is in progress the child should 
wear a cap, day and night. This may be made of any cheap, light- 
weight material, which, after a day or two of use, may be burned. In 
our cases cheese-cloth caps were used. Rubber gloves were necessary 
to protect the hands of the nurse who made the applications, especially 
if there were many heads to be treated. 

In this epidemic, which was controlled by the above means, 
prophylaxis was obtained by the use of the kerosene and olive oil with- 
out the bichlorid. It was found impossible to maintain a quarantine 
permanently or effectually even for a short time, particularly during 
the warmer months. Therefore every inmate of the asylum of the 
"runabout" age who did not have the disease was treated as an in- 
cipient case. Every head was '^ clipped" and the hair kept short. 
Twice a week the children were given a kerosene and olive oil 
shampoo. 

In private work the continued use of kerosene and olive oil is not 
popular, for reasons readily understood. In such cases the hair should 
be chpped as soon as the case is diagnosed, and a kerosene shampoo 
given. The bichlorid of mercury, 2 grains to 1 ounce of tincture of 
iodin, U. S. P., should be applied to the parts with sufficient vigor to 
produce a dermatitis. If the disease shows a tendency to spread be- 
yond the original site, it is best prevented by the use of the kerosene 
and olive oil, in the manner above described. Bulkley* claims that all 
cases are cured spontaneously at puberty as practically no cases are 
seen in the scalp of the adult. 

Stricklerf reports favorably on the results of 20 cases of ring- worm 
of the scalp treated by vaccines. 

Roentgen-ray Treatment of Ring-worm of the Scalp. — With many 
improvements in technic and apparatus a;-ray treatment is now com- 
paratively without danger and offers a very speedy cure. The treat- 
ment must be in the hands of experts. 

The efficacy of the treatment is due to the falling out of the infected 
hairs carrying with them the organisms. There is no direct action of 
the parasite so that precautions must be observed after treatment to 
prevent the infection of others by the falling hair. This is easily ac- 
compHshed by keeping tha head covered. About seven days after 
ic-ray treatment a local erythema develops, lasting three to four days. 
The hair falls out about the end of three weeks and begins to re-grow 

* Journal A. M. A., July 17, 1915. 
t Journal A. M. A., Aug. 17, 1912. 



PEMPHIGUS NEONATORUM 579 

in three months. No local treatment is used two weeks prior to treat- 
ment and for one month afterward when a 5 per cent, ointment of 
sulphur or of ammoniated mercury U. S. P. is applied. (For com- 
plete details of technic consult Mackie and Remer, Medical Record, 
N. Y., Vol. LXXVIII, p. 217.) 

IMPETIGO CONTAGIOSA 

Impetigo contagiosa, as the name implies, is a contagious disease 
of the skin. Several children in the same family or school often have 
the infection at the same time. I have known one school-child to 
infect an entire class of 20. Cases of impetigo are seen almost daily 
in large out-patient clinics for children. The exposed parts comprising 
the face, head, and hands are those most frequently involved. 

Etiology. — Bacteriologic examination shows a mixed infection with 
staphylococcus predominating. 

Symptoms. — At first the lesion consists of a few closely grouped 
vesicles, which rapidly develop into pustules. These shortly form a 
dry crust of variable size and thickness. One area or a dozen or more 
may be involved. Several small lesions may coalesce, forming one 
large lesion. I have seen the crusts two inches in diameter. They 
rest upon an inflamed base, which bleeds slightly when they are re- 
moved. There are no constitutional symptoms, and rarely is there 
itching. The only evidence of the disease is the disfigurement occa- 
'sioned by the dry, adherent crusts. 

Treatment. — The most satisfactory procedure has been to soften 
the crusts by the application of gauze saturated with sterilized olive 
oil, the gauze being bound to the parts. Usually in twenty-four hours 
the crusts may readily be removed. Afterward an ointment of 10 per 
cent, boric acid in ointment of rose-water, or one composed of 10 per 
cent, ichthyol in vaselin, should be spread on sterile gauze and bound 
to the suppurating surface. The dressing should be changed at least 
night and morning. Recovery is usually complete in from two to 
three days. When the crusts are on the lip or other portions of the 
face where the dressing described cannot readily be applied, the lesions 
should be kept moist with either the boric acid or ichthyol ointment. 
If the gauze is not used, fresh ointment should be applied at least every 
three hours, both before and after the crusts are removed. 

PEMPHIGUS NEONATORUM 

Pemphigus in the newly born is an infection of the skin manifesting 
itself in a bullous eruption, which may appear on any portion of the 
surface. There have been two epidemics of pemphigus at the New 
York Infant Asylum, involving in all about 30 cases. The patients 
were mostly well-nourished infants. The origin of the disease in each 
epidemic was unknown. From a few hours to a day after birth the 
bullae of the seropus appeared, and in several cases the process was so 
extensive through their coalescence that large portions of the skin sur- 
face were denuded when the bullae ruptured. The disease is very con- 



580 THE PRACTICE OF PEDIATRICS 

tagious, and these epidemics were only stayed by rigid quarantine of 
all the newly born and by closing the operating room. Examination 
of the serum from the bullae of several cases showed the Staphylococcus 
albus. The mortality was about 20 per cent. 

Treatment. — The management of the first epidemic consisted in 
opening the blebs and in the application of various antiseptic solutions 
and ointments. Not much improvement followed until creolin baths 
were used. This treatment not only relieved those cases which had 
developed, but the systematic bathing in a 1 per cent, creolin solution 
of all the newly born in the institution apparently prevented the spread 
of the infection. 

During the second epidemic the house physician, Dr. Carswell, be- 
lieves that favorable results were obtained with a 30 per cent, solution 
of ichthyol kept applied to the parts and changed three times a day. 

ERYTHEMA NODOSUM 

Erythema nodosum is characterized by the formation, in the skin 
and connective tissue, of multiple brownish nodules of varying size. 

Location of the Lesion. — The nodules are most frequently seen over 
the anterior surface of the leg. 

Etiology. — I look upon the disease as an infection — one of the many 
protean manifestations of rheumatism. In my cases endocarditis has 
not been a complication. All my cases have been in rheumatic sub- 
jects, and associated with peliosis rheumatica. 

Symptoms. — Previous to the appearance of the nodules, there may 
be fever and loss of appetite and general indisposition on the part of 
the child. According to my observation these prodromal symptoms 
have, however, been unusual, the local manifestations constituting 
prominent symptoms, and in some cases the only evidence of the dis- 
ease. The nodes are very painful to the touch, and show a black and 
blue discoloration. The entire anterior surface of the tibia may have a 
bronzed appearance. 

Pigmentation follows the disappearance of the nodules. 

In mild cases the pain is confined to the lesions. In severe attacks 
there is not only fever, as already mentioned, but also a great deal of 
joint pain and muscle soreness. 

Treatment. — If there is fever, the patient should be kept in bed 
until the acute febrile period is passed and the nodules begin to dis- 
appear. The treatment is begun with the administration of one or two 
grains of calomel, followed by a saline laxative. 

Milk and a vegetable diet are prescribed. A very small amount 
only of sugar is permissible. As a rule, my best results from drug 
therapy have been gained by the use of 5 grains of the salicylate of 
soda (wintergreen) in combination with 10 grains of sodium bicarbon- 
ate in 6 ounces of water after meals. 

Illustrative Case. — A delicate girl had three crops of nodules, the different crops 
having appeared at intervals of about three months. The first attack was asso- 
ciated with peliosis and urticaria. The treatment which I had employed success- 
fully previous to this case consisted of the use of the salicylate and bicarbonate of 



ERYSIPELAS 581 

8oda. This patient, who is markedly rheumatic, had taken large quantities of the 
salicylate, and its readministration had no effect; but in all three attacks the nodules 
began to diminish and disappeared completely under the administration of 30 
grains of iodid of potash. 

The duration of my cases has been from ten days to three weeks, 
with the exception of the one referred to, which persisted for six weeks, 
until the iodid was brought into use, when the improvement was 
prompt. 

Local Measures. — The most satisfactory local application for the 
relief of pain is the lead and opium solution, U. S. P., applied warm to 
the parts by means of soft old linen or gauze, oven which oiled silk or 
rubber tissue is placed, to prevent too rapid evaporation, the entire 
dressing being held in position by bandages. 

ERYTHEMA MULTIFORME 

As its name indicates, this is a disease of the skin manifesting itself 
in many different forms. 

Etiology. — It is most frequently encountered in ill-conditioned 
children of rheumatic inheritance, and is frequently associated with dis- 
orders of digestion. 

Symptomatology. — The disease usually manifests itself in reddened 
papules, macules, and erythematous, infiltrated skin areas, all of which 
are most frequently found over the dorsal surfaces. There is no pain 
and but little if any itching. 

Diagnosis. — The condition is to be differentiated from acute urti- 
caria by the fact that in urticaria the lesions are very transient, appear- 
ing and disappearing rapidly, while in erythema multiforme several days 
are required for resolution to take place. 

Treatment. — The management consists in relieving whatever diges- 
tive derangement may exist by the use of calomel, rhubarb and soda, 
and the enforcement of a suitable diet (p. 102). 

For a child five years of age 3 grains of salicylate of soda with 6 
grains bicarbonate of soda in 4 ounces of water should be given after 
meals three times daily. In the event of itching, which is unusual, an 
ointment composed of 10 grains of menthol in 1 ounce of rose-water 
ointment will usually furnish relief. The eruption seldom lasts longer 
than a week. A pigmented area may remain at the site of the lesion. 

ERYSIPELAS 

Erysipelas is a serofibrinous inflammation of the skin, and may go 
on to the stage of gangrene. It is caused by the streptococcus, which 
enters through a wound or abrasion and spreads along the lymph- 
channels. Strains of streptococcus isolated from the lesion of erysipelas 
cannot be differentiated by any known test from other strains isolated 
from a case of scarlet fever or from a suppurating focus anywhere in 
the body. 

In newly born infants the umbihcus may be the point of entrance for 
the streptococcus, and erysipelas of the surrounding portions of the 
body-wall may result. 



582 THE PEACTICE OF PEDIATRICS 

Etiology. — Infants with low resistance are predisposed. Thus a 
majority of my cases were seen in the New York Nursery and Child's 
Hospital. Nevertheless, babies ideally cared for are sometimes victims 
of the infection. The absence of resistance of the young to bacterial 
invasion is unquestionably a factor in determining the age incidence. 

Mode of entrance: In the newly born the streptococcus may enter 
the skin by the nasal route, or the navel may be the seat of the initial 
infection. Later in development the process may begin in any portion 
of the skin surface. The scalp perhaps is the favorite site. 

Symptoms. — The first sign may be fever, the cause of which is not 
known until a reddened, indurated area with sharply defined border is 
found at some point in the body. The infection, when not very severe, 
may invade the scalp and continue to spread unrecognized because of 
the protection of the hair. Usually a considerable area, at least two or 
three inches in diameter, will be present when the disease is discovered. 
From this primary area there is a slow progressive spreading of the pro- 
cess, the margins of the affected zone remaining sharply defined. The 
inflammation may be arrested at any point or it may involve the entire 
body. The slowly creeping red line of demarcation at all times sharply 
defines the normal skin from the reddened infected skin and subcu- 
taneous tissue. The portions involved swell to two or three times the 
normal size. The skin over the feet and hands may be swollen almost 
to the point of rupture. Severe infections are never followed by re- 
covery. If the case is mild, the general process will be less intense, the 
creeping extension less rapid, and the response to treatment more 
prompt, permitting recovery. 

The temperature is very high — usually 104° to 106°F. — with but 
little variation. The height of the temperature is indicative of, the 
severity of the infection. In mild infections only the fever may be slight. 

With erysipelas the child is very uncomfortable and restless and cries 
much, giving evidence of considerable pain, particularly upon manipu- 
lation. 

Complications. — Erysipelas does not predispose to any particular 
form of illness. Patients who resist the infection may develop broncho- 
pneumonia as a terminal complication. 

More often the digestive system becomes involved, the child loses 
weight rapidly, and dies from exhaustion. 

A complicating meningitis is not an infrequent cause of death. 

Prognosis. — Erysipelas is a particularly fatal disease in infants. 
In the new-born, 95 per cent, of the cases are fatal. Fifty per cent, of 
my cases occurring in children under one year of age have been fatal. 
When the streptococcus of erysipelas gains entrance into the skin of an 
infant, it is unusual for the entire skin surface not to become involved 
before the process subsides. The long-continued high temperature, 
the toxemia, the discomfort from the inflammation, and the interfer- 
ence with nutrition so greatly reduce the patient that even if the disease 
is resisted during the acute stage the subject is very apt to die later from 
exhaustion. 



J 



ERYSIPELAS 583 

This was the outcome in four cases recently at the New York Infant Asylum, 
where each child went through the active period of the disease, but died a week or 
two afterward from exhaustion and marasmus. 

Treatment. — The treatment is unsatisfactory, particularly so in 
young children. The younger the child, the graver the prognosis. 
Absolutely nothing is to be promised. I have employed scarifications 
in advance of the line of the slowly creeping inflammation, and whether 
solutions of the bichlorid of mercury, carbolic acid, or ichthyol were 
used as a dressing, I have seen the red line pass the scarified, disinfected 
surface, regardless of the nature of the anticeptic and regardless of the 
vigor and vitality of the child. 

The termination of the case, whether in recovery or death, depends 
to a great extent upon the resistance of the patient and the severity of 
the infection, so that our first step should be to place the child in the 
best position to resist the disease. 

General Measures, — Perhaps the most important factor in the treat- 
ment is abundance of fresh air. In the winter the child does best in a 
room with windows wide open, not for a few moments at intervals, but 
continuously. Protection with hot-water bags and sufficient clothing 
eliminates danger, as long as the temperature of the room does not fall 
below 55°F. At other seasons of the year the patient should, if pos- 
sible, be kept out-of-doors. 

Infants with erysipelas are particularly liable to develop gastro- 
enteric disorders. In case the child is bottle-fed, the milk mixture 
should at once be reduced from 50 to 75 per cent, below the normal by 
the addition of barley-water or granum- water No. 1, so that the 
amount of fluid given at a feeding remains unchanged. 

Internal medication, such as I have used, has been of no value unless 
stimulating or sustaining in nature. The tincture of the muriate of 
iron is not to be given young infants with erysipelas, for it almost invari- 
ably disturbs the appetite and interferes with the digestion. 

In the event of high temperature — above 104°F. — the cool pack 
(p. 777) may be found effective. 

Local Applications. — The local agent which is unquestionably of 
some value is ichthyol. I prefer a 30 per cent, solution if the involved 
area is on one or more of the extremities or a small portion of the trunk. 
Solutions as dressings should not be used for infants when the erysipe- 
latous process involves the face or much of the trunk. When these 
parts are involved, a dressing of 30 per cent, ichthyol ointment in vaselin 
should be applied on strips of lint or linen and renewed every three 
hours. The frequent renewal is important, and the ointment-dressing 
should be used only on the acutely involved areas. When, in a given 
case, the inflammation begins to subside, the dressings should be re- 
moved and the parts bathed freely. In this connection it must be re- 
membered that the skin is an important organ of excretion, particularly 
of carbon dioxid. The constant covering of comparatively large sur- 
faces on a small body, by interfering with the function of the skin, may 
become a serious matter. The local treatment with ichthyol should 



584 THE PRACTICE OF PEDIATRICS 

follow up the extension of the inflammatory process and be continued 
until it subsides. Of later years I have been using with a fair degree of 
success, a wet dressing of a saturated solution of boracic acid. The 
lotion is applied on old linen or several thicknesses of gauze. The parts 
are kept continually wet with the solution day and night. 

Stimulants. — Nearly every infant with erysipelas will require stimu- 
lation. For this purpose small doses of whisky well diluted appear best. 
From 5 to 15 drops at two-hour intervals for children under two years 
of age has aided me, I am sure, in carrying the patients through to a 
successful convalescence. Erysipelas is the only disease in which it is 
wise to use alcohol early, and in many instances as the only stimulant. 

Convalescence. — When the inflammation subsides, the child is by no 
means to be regarded as well ; for even in the absence of sequelae, such 
as a phlegmon, endocarditis, or nephritis, vitality may have become so 
reduced that sudden death may take place when it is thought the pa- 
tient is well on the road to recovery, such a result being due, perhaps, 
to an unrecognized myocarditis. During the entire attack and 
throughout convalescence the child should be fed to the limit of diges- 
tive capacity, but never beyond this limit. Correct feeding is possible 
only by careful observation of the case and frequent inspection of the 
stools. 

Vaccine Therapy. — The value of vaccine therapy in this disease 
remains to be proved. (See p. 797.) 

ECZEMA 

In the consideration of eczema we are dealing with a disease which is 
very frequently encountered in infants. If we group together all the 
skin diseases of infancy and childhood, it will be found that eczema 
considerably exceeds in prevalence all the others combined. This is 
not surprising when we remember the exposed situation of the skin, its 
delicate structure, and its manifold functions of absorption, secretion, 
excretion, and heat radiation. 

Etiology. — Grossly, eczema as it occurs in infants may be divided 
into two types; the first, due to causes operating from without the 
body, including local infection of various kinds or local irritation of 
whatever nature; the second, due to abnormal systemic conditions 
affecting the skin through the nervous system or by means of the blood- 
current. Cases of this latter class are looked upon as of toxic origin. 
The irritation of the skin or the skin lesion is actually the secondary 
manifestation of a disordered constitutional state. Upon the non- 
resistant skin lesion, infection is implanted through exposure to the air 
or through scratching, and the result is an eczema in which both causes 
are operative. This is the etiologic explanation of the majority of 
the cases in patients under two years of age. 

In view of the foregoing it is plainly not possible, even were it de- 
sirable, to make the attempts at differentiation, such as is found in text- 
books dealing with dermatology in the adult. Repeatedly one will find 
a weeping or catarrhal eczema in one portion of an infant's body and 



ECZEMA 585 

on other portions every variety of inflammatory lesion, including 
papules, vesicles, pustules, and fissures. Moreover, a weeping sur- 
face may be replaced by perfectly normal skin within a day or two 
and then suddenly return within a few hours under some dietetic 
indiscretion. 

Infection of the involved areas by pyogenic bacteria, resulting in 
pustules and furuncles, is more common in infants than in adults, 
because of the child's greater tendency to inoculation through manipu- 
lation and scratching, and because of the dimished resistance offered 
by a child to pathogenic organisms. 

Toxic Origin. — The cases of eczema that are due to disordered 
metabolism or to digestive derangements are the most frequently en- 
countered and by far the most resistant to treatment. 

The Age. — The susceptible age is from one to twelve months. While 
cases which have developed during the earher months of life may per- 
sist into the second and third years, so long a duration is comparatively 
rare, and it is equally rare for cases to develop after the first year, the 
latter fact implying that many are cured spontaneously. 

Physical Condition. — The physical condition and vigor of the child 
exert no influence upon the development of the disease. Some of my 
healthiest nursing babies who have made most satisfactory progress 
and have been well in every other respect have been sufferers from 
eczema until the nursing period was over or until nursing was discon- 
tinued and other food given. In fact, the majority of my cases have 
occurred in children whose condition was otherwise satisfactory. 
There have been other patients, to be sure, who have suffered from 
malnutrition or been difficult feeding subjects. In some of these ec- 
zema was possibly a factor in causing the malnutrition, for on account 
of the excessive itching and consequent restlessness and sleeplessness, 
strength had become so markedly reduced that malnutrition was just 
as probably a result as a cause of the eczema. Nevertheless, a con- 
sideration of all the cases encountered indicates that athreptic and 
poorly nourished children are surprisingly free from eczema of an 
acute inflammatory type. Whatever process is at fault is usually of 
such a nature as not to interfere with nutrition. 

In a considerable proportion of the cases there will be an associated 
eczema of the scalp. 

Several of my patients who have been sufferers from eczema in 
babyhood have in later life developed some tendency to cyclic illness, 
such as recurrent bronchitis, recurrent asthma, or recurrent (cyclic) 
vomiting. Not a few of my eczema patients have been the offspring 
of parents who gave a history of gout. 

Carbon Incapacity. — While it is not claimed that the presence of 
carbohydrate and hydrocarbons in the infant's food is the sole cause of 
these forms of toxic eczema, my observation, covering many hundreds 
of cases, leads me to believe that a carbohydrate (sugar) incapacity 
exists in all. I look upon a great majority of the cases as exhibiting 
in capacity for fats (hydrocarbons) and certain carbohydrate foods, 



586 THE PRACTICE OF PEDIATRICS 

an intolerance which may be manifested by the skin lesions and in no 
other way. 

The ingestion of fats and cane-sugar is the most prominent etio- 
logic factor in causing eczema in the young. Carbohydrate in the 
form of baked flours appears to exert but little influence. Orange-juice 
and beef -juice when given in association with a high sugar diet will pre- 
cipitate an attack in some children or produce recurrence in a recovered 
case 

A possible reason for the frequency of eczema in the young is that 
the young child is unable to adjust himself to the many varieties of 
food and food elements that are given him whether natural or artificial. 
Not all cases of eczema in infants admit of a cure and yet I believe 
that all cases might be cured if we dared draw our dietetic lines suffi- 
ciently rigid. This might mean a clear skin but it also might mean 
faulty growth and malnutrition. I have now and then an infant 
whom I have entirely cured but do not dare to keep him entirely 
eczema free because of loss in weight. I believe that proper growth 
and right development are more important than personal appearance. 

Local Irritation as a Factor. — Traumatic eczema may be produced 
by any form of irritation, such as woolen worn next to the skin, counter- 
irritants applied for therapeutic purposes, overclothing in hot weather, 
or scratching to relieve the itching caused by the bites of insects. 

Symptoms. — The symptoms of eczema cover so wide a field that a 
description is most difficult. A red inflamed area on the cheek and an 
extensive acute general dermatitis constitute the two extreme possi- 
bilities of the acute lesions. Between these extremes there is every 
degree of involvement. 

When an infection with the staphylococcus supervenes we may ex- 
pect all possible varieties of pustules and furuncles, and the case may 
show, throughout, the characteristics of chronic eczema in the adult: 
dry, scaly, desquamating epithelium on extensive reddened surfaces, or 
infiltrated skin areas with diffuse macules and papules and abundance 
of scratch-marks. The extensor surfaces of the arms and legs are the 
most frequent sites of election by this form. 

Prognosis. — Eczema is one of the diseases that require patient and 
persistent treatment of the right kind. The prognosis is then good, 
and the results fairly prompt. The disease does not tend toward 
recovery, particularly during the first year, although many cases 
developing during the first month get well spontaneously during the 
second year. In a few subjects the tendency persists during the life- 
time of the individual. 

Treatment. — The management is variable, depending upon several 
factors. 

Management of the Breast-fed. — If the child is a well-nourished, 
breast-fed baby and presents the familiar picture of the red, weeping 
cheeks, with dry crustations extending to the forehead and ears, 
seborrhea of the scalp, and roughened skin over the outer aspect of the 
arms, my first step is to look into the fife and habits of both child and 



ECZEMA 587 

mother. The mother's life and the nursing hours are to be regulated 
along the lines laid down under maternal nursing (p. 21). A most im- 
portant requirement of these cases is that the mother's bowels shall be 
evacuated at least once daily and that the same function shall take 
place in the baby. In a case of the character described the child has 
usually been getting too much food, and probably food high in fat. 
The mother's milk should be examined and the baby weighed before 
and after nursings for twenty-four hours in order to determine the 
amount of milk taken at a feeding. As a general observation it will 
be found that these children do best on four-hour nursings, at 6, 10, 2, 
6, and 10 p. m. If the mother's milk is found to contain an excess of 
fat, one ounce or two of water or barley-water should be given before 
each nursing to diminish the amount of fat ingested. 

For the correction of constipation in the mother I frequently pre- 
scribe the following laxative: 

I^ Ext. belladonnse gr. iv 

Ext. nucis vomicae gr. viij 

Ext. cascarse sagradae 5ij 

M. Div. in capsulas no. xxx. 

Sig. — One at bedtime. 

By applying this form of management to the mother and child I 
have repeatedly known the eczema to subside very promptly. In 
other cases I have seen it improve; and in still others persist without 
the slightest benefit. 

The problem which confronts us may be rendered difficult in differ- 
ent ways. If the child is her first offspring, the mother feels keenly the 
disfiguring condition and demands a prompt cure. If this is not forth- 
coming within a few weeks she seeks new medical advice. My advice 
concerning the persistent breast-fed cases is for the mother to continue 
to nurse the thriving child and tolerate the eczema. Local treatment 
should be prescribed to relieve as much as possible the child's distress. 
The mother may be told that at the time of weaning the eczema will 
probably disappear. If weaning is insisted upon, the patient forth- 
with becomes a bottle-fed infant and is treated accordingly. The 
•eczema often, but not invariably, clears up promptly when nursing is 
stopped. 

Management of the Bottle-fed. — Every year I see many aggravated 
cases of eczema in bottle-fed babies who have been treated elsewhere, 
often by dermatologists, without benefit. Failure usually has been due 
to the fact that while a great deal of attention has been paid to local 
measures, little if any has been directed to the feeding and other details 
of the constitutional care. 

Let it be understood that local applications in the form of lotions, 
ointments, or powders have but two uses in the treatment of eczema in 
children. Their chief use is that of a sedative. In other instances a 
stimulant is required and may be supplied by local measures as a 
means of permanent cure. Local treatment, however, is attended with 
disappointment. The external condition may be temporarily relieved 



588 THE PRACTICE OF PEDIATRICS 

in a marked degree, but if the underlying systemic toxic condition 
exists, the disease returns with renewed vigor. 

In caring for the bottle-fed I find that the most prompt results fol- 
low when food low in both fat and sugar is given. I specify the use of 
skimmed milk diluted with a cereal decoction made usually from bar- 
ley flour or Imperial Granum. Sugar is to be avoided. For a child 
under one year of age, from 12 to 24 ounces of skimmed milk are added 
to sufficient cereal water to make 32 ounces. One and one-half ounces 
of either of the above flours are required. The mother or nurse is told 
that the child is not expected to gain rapidly on this formula. 
Perhaps no gain will occur for a few weeks, but only a very stubborn 
case will fail to show some response to the change in the diet. If con- 
stipation follows the change in the food, magnesia in some form — cal- 
cined, or milk of magnesia — may be added to the day's ration in suffi- 
cient amount to keep the bowels relaxed and the bicarbonate-of-soda 
is omitted. If the response to treatment is not satisfactory, or if the 
milk does not agree with the patient, I employ an evaporated fat-free 
milk made for me by Borden & Co., 106 Hudson St. Each ounce rep- 
resents two and two-fifth ounces of skimmed milk. In feeding, one 
part of this milk is added to from three to six parts of the 6 per cent, 
carbohydrate gruel. Whether ordinary skimmed milk or the special 
evaporated milk is employed, this method of feeding is continued only 
until the skin condition warrants an increase, and then the change is 
made to full milk with the gruel diluent. In some instances sugar is 
not used for weeks. In case evaporated milk has been given, the change 
to plain milk must be made most gradually, one bottle of plain milk 
replacing one of the feedings of evaporated milk every two or three 
days. In the event of a return of the eczema, it may be necessary to 
resume the former diet, . consisting of the skimmed milk or evaporated 
milk, and perhaps to discontinue full raw milk entirely. 

Illustrative Case. — One of my patients, a baby otherwise normal, had a most 
pronounced general eczema, the entire skin surface being involved. For seven 
months — until he was past one year of age — I was unable to give this patient 
more than 1 per cent, of fat. An increase to 1.5 per cent, of fat would be followed 
in half an hour by intense inflammation and redness of the skin. 

In another case, almost as severe, which I saw at the ninth month, I was unable 
to give plain milk in any form. The condition was so aggravated that I discon- 
tinued entirely the fresh cow's milk and gave the child only evaporated milk, 
whereupon the skin cleared up promptly without any other treatment whatever. 
After about six weeks a further trial of full milk in small quantities was at once 
followed by a prompt return of the eczema. At different intervals the plain milk 
was given for one or two feedings daily, but this we were always obliged to dis- 
continue, because of the signs of the old trouble which immediately reappeared 
after two or three of such feedings. 

In treating these obstinate cases, as the urine is usually very acid 
and a deposit of urates will be found on the napkin, I invariably give 
bicarbonate of soda, one grain to one ounce of food, or ten grains of 
citrate of potash five or six times daily. I look upon citrate of potash 
in fairly large doses, five to ten grains every two hours, as a valuable 
aid during the acute stage of eczema. It may be discontinued after 
the erythema and weeping has subsided. 



ECZEMA 589 

If a high fat feeding has been practised, cure may at times be 
effected simply by the use of full cow's milk, with the gruel diluent. 

The successful management of eczema (non-traumatic) depends 
upon our ability to discover the disturbing food factors, to eliminate 
them if we dare, or if possible immunize the patient to such food or 
foods. 

Local Treatment. — In view of what has been said, little is to be ex- 
pected from local measures. As a rule, too strong lotions and oint- 
ments are employed and help to keep up the irritation, producing harm 
rather than benefit. Vaselin is often used as a base, and this in itself 
is irritating to many skins. In facial eczema of an active type in young 
infants, however, the parts should be protected from scratching and 
pillow-rubbing. This is best accomplished by the use of a mask (p. 
591) under which are placed strips of old linen on which the following 
paste ointment is applied: 

I^ Pulv. zinci oxid, 

Pulv. amyli aa 5ij 

Ungt. aq. rosse q. s. ad Sij 

This ointment should be freshly applied three times daily. The child's 
skin is not to be bathed with water, but cleansed with sterilized sweet 
oil. When the weeping has subsided, some preparation of tar may be 
employed. An ointment composed of unguentum picis, U. S. P., 1 part, 
with unguentum aquae rosse, from 4 to 6 parts (the strength used de- 
pending upon the irritability of the skin), may be applied with much 
benefit morning and evening. The ointment should be thickly spread 
over old linen and held firmly, yet without great pressure, over the 
parts. If the existing irritation is at all increased, the amount of tar 
used must be diminished. If the itching is not considerably relieved 
by the application, 5 grains of menthol or 5 grains of salicylic acid may 
be added to each ounce of the ointment. For the weeping or intensely 
inflamed surface, Euresol (Merck) has been used by me with a great 
deal of benefit. In this stage it is best used in a solution of 1 to 3 per 
cent. The solution is to be applied very gently and allowed to dry. 
It may be applied at intervals of three to four hours. When the weep- 
ing ceases and the skin becomes dry and desquamating, an ointment 
of Euresol 1 per cent, to 2 per cent, in unguentum aqua rosse, applied 
three times daily often supplies very substantial relief. 

Bathing. — All infants and young children suffering from generalized 
eczema should not be bathed. Water is a decided irritant to the skin. 
For cleansing purposes during the acute stage sterilized olive oil or 
liquid albolene may be used. When the skin permits of bathing, the 
patient should have the advantage of the soda or bran bath (p. 780). 
Unnecessary friction is to be avoided at all times. 

Clothing. — It is my custom to have the clothing which comes in 
contact with the skin lined with thin linen. Wool worn next to the skin 
will frequently retard recovery. 

Traumatic Eczema. — The successful management of eczema due to 
external causes consists in the removal of the source of the irritation. 



590 THE PRACTICE OF PEDIATRICS 

In some cases lining the underclothing with old linen or the use of linen 
mesh underwear will solve the entire problem. Local treatment, when 
necessary, is afforded by the soothing and stimulant applications pre- 
viously described. 

ECZEMA INTERTRIGO OR ERYTHEMA INTERTRIGO 

This form of eczema is an affection resulting from persistent ir- 
ritation due to moisture or friction. The primary condition of macera- 
tion soon develops into a chronic eczema. This occurs with greatest 
frequency in fat children, but may develop in any child through neglect. 
In fact, intertrigo is often a mark of ignorance and neglect. 

Location. — The parts most affected are the lower abdomen, the 
inner aspects of the thighs, and the buttocks. In neglected cases I 
have repeatedly seen the process cover the entire skin surface from the 
umbilicus to the lower third of the thigh. Other parts usually found 
affected are the skin folds of the neck, the groin, and axillae and the 
flexor surfaces at the elbow-joint where contiguous portions of skin are 
subjected to chafing. 

Neglected, athreptic, and poorly nourished babies afford many of 
these cases. Among out-patients, I have seen infants who presented a 
series of linear ulcers in the groin, productive of entire destruction of 
the skin. In a few such instances resulting infection of the glands in 
the groin has produced an inguinal adenitis. 

Prognosis.-— All cases recover promptly if proper care is exercised 
in carrying out the suggestions offered. 

Treatment. — The management consists in separating the opposed 
diseased surfaces by pledgets of cotton, gauze, or old linen, freely 
dusted with equal parts of starch and oxid of zinc. As soon as the 
material becomes moist a fresh dressing should be substituted. 

When there is much associated involvement of the skin over the 
genitals, lower abdomen, thighs, and buttocks, care must be exercised 
that the parts be kept free from decomposing urine. 

Except in cases of the seborrheic type (p. 595) the management 
consists in neutralizing the urine by the use of bicarbonate of soda, 
three grains three times daily, and in protecting the skin surface from 
irritating discharges by attention to the napkin. Dusting-powders are 
of very little use. 

A most satisfactory procedure which I have followed with success 
for years, even in the most unpromising cases, is as follows : The mother 
or nurse is instructed to keep close watch of the napkin and change it a& 
soon as it is soiled. She is further instructed to prepare pieces of gauze 
or old linen of such shape and size as to cover the denuded surfaces. 
On these slips of Unen she is directed to spread a thick layer of zinc oint- 
ment (U. S. P.) to which 10 per cent, white wax has been added. This 
dressing is kept applied to the parts and is to be changed several times 
daily. If the ointment is simply spread over the skin, it will soon be 
absorbed by the napkin and be of no service. 

Over the dressing the napkin is placed. The irritating urine is- 



ECZEMA IN OLDER CHILDREN 



591 



thus prevented by the ointment dressmgs from commg in contact with 
the skin. An additional quantity of absorbent cotton placed next to 
the genitals serves to absorb the urine as it is passed and thus prevents 
its general distribution over the parts. When the case is well advanced 
toward recovery, the maintenance of scrupulous cleanliness and the 
apphcation of a dusting-powder composed of equal parts of powdered 
starch and oxid of zinc will be sufficient. 

The Mask. — The itching produced by facial eczema is often most 
intense. In order to effect a cure, scratching and rubbing the parts 
must be prevented. The Herty 
mask (Fig. 77) fulfils this pur- 
pose admirably. The ointment 
or lotion is placed on clean 
linen, which rests on the in- 
volved parts, and over this is 
placed the mask, a pattern of 
which is shown in Fig. 78. 
Opening A is sufficiently large to 
furnish space for the eyes, nose, 
and mouth. An elastic band, 
passing over the upper lip, draws 
the sides of the opening together, 
insuring protection to the cheeks, 
which are usually most severely 
affected. B and C pass over the 
ears to the back of the head, 
where they are united. The 
mask, which should be made of 
mushn or thin old linen, is to be 
renewed daity. 

The Strait-jacket — The tendency for the patient to scratch the 
involved parts not only keeps up the trouble indefinitely, but opens a 
way for the development of severe dermatitis, furunculosis, and cellu- 
litis as a result of infection from the finger-nails. One of the best agents 
for preventing scratching during the sleeping hours is the Thomas 
modified strait-jacket (Fig. 79). This is made of mushn and must be 
fitted to the patient. The child is slipped into the jacket feet first. 
The opening A incircles the thorax directly under the arms. The 
opening B is closed about the neck with the attached tapes. The cord 
which is used to close the end of the sleeves may be tied to the side of 
the crib or pinned to the bedding. Children readily accustom them- 
selves to lying on the back, a posture which the use of the jacket 
necessitates. 

It is no kindness to allow a child to continue the irritation of sur- 
faces already badly involved. 

ECZEMA IN OLDER CHILDREN 

We have been considering eczema in children under two years of 
a^e. From the eighteenth month to the second year certain develop- 




Fig. 77. — The Herty mask in position. 



592 



THE PRACTICE OF PEDIATRICS 



mental changes take place in the child which render him much less 
susceptible to the toxic agents capable of producing the eczema. 
The ratio of cases seen after the second year to those under one year 
of age is about one to ten. 



t 




Fig. 78. — Pattern for the Herty mask. 

Etiology. — Gouty antecedents have been the rule in my cases. 
In older children as well as in the young, eczema is of metabolic and 
gastro-intestinal origin. We find that in the causation certain sub- 




Fig. 79. — Thomas' modified strait-jacket. 



stances play an important part, particularly milk-fats and sugars. 
Certain fruit acids and meat extractives have also proved operative 
in an etiologic way. Thus grape-fruit, orange-juice, strawberries, 
tomatoes and beef-juice have all been proved the immediate cause in 
a sufficient number of cases to establish the mode of origin beyond the 
slightest doubt. 



ECZEMA IN OLDER CHILDREN 



593 



Some of the cases of eczema in children are unquestionably of 
intestinal origin owing to the absorption of toxic substances from the 
intestinal canal. Such origin of the disease may be suggested by habit- 
ual constipation, light colored and foul stools, and distended abdomen. 
This mode of etiology has further been proved by the recovery and 
continued well-being of the patient when the constipation is relieved 
and a rational, simple diet free from milk-fat and excessive sugar has 
been instituted. Finally, it is to be remembered that in older children 
anemia and malnutrition may play an important part in causing 
eczema. 

Symptoms. — The cases of acute facial eczema are comparatively 
rare except in younger children, but are occasionally encountered. 




Fig. 80. — Thomas' modified strait-jacket in position. 



The tendency to development of pustules and furuncles is also much 
less in children over two years of age. Weeping and desquamating 
surfaces, however, are common, and squamous patches and fairly 
extensive infiltrated areas are frequently found in different portions of 
the body. Perhaps the most frequent manifestation at this age is 
what is referred to by various writers as "neurotic" or "reflex" 
eczema. The predominating lesions in this form are papules which 
may exist in great number, especially over the extensor surfaces of 
the arms and legs. Often the individual papule is tipped by a black 
speck which represents dried blood and dirt resulting from scratching. 
In cases that have existed for some months there is a general thickening 
and hardening (infiltration) of the affected skin, with surrounding spots 
of inflammation, which is more the result of trauma from treatment 
than due to the disease itself. 
38 



594 THE PRACTICE OF PEDIATRICS 

Eczema, by reason of the wide variety of its forms, may involve 
any portion of the skin. The skin about the umbilicus is one of the 
sites occasionally selected by the disease in older children. 

Illustrative Cases. — One of my most troublesome cases, which had been treated 
by various physicians for two years, was that of a girl four years of age who pre- 
sented a round, red, desquamating area on the right cheek, ^i inch in diameter. 

In the case of a boy four years old an acute weeping eczema had covered both 
buttocks. 

A girl of five had suffered at intervals for eighteen months with an eczema 
between the fingers of the right hand. 

I have a most interesting girl patient of eight years, who, after partaking of 
sugar in any form and in the smallest amount, beef-juice, or any acid fruit-juice, 
will develop an acute eczema of the face, requiring two weeks for recovery. The 
mother, who is very intelligent, had discontinued milk before the case came 
under my observation because of attacks of cyclic vomiting from which the child 
suffered, and which the mother stated were worse when milk was taken. Milk 
also produced hives and "poisoned" the child, so that the mother begged me 
not to ask her to give the patient milk. We found that the child could take fat- 
free milk. In this case there was a marked history of gout on both sides of the 
family. The maternal grandmother required crutches, the mother had cyclic 
vomiting as a child and sick headaches as an adult, and "had been treated for 
uric acid all her life," and the father stated that he was scarcely ever free from pain 
in his joints or muscles. 

Another girl four years old, of decidedly gouty ancestry, suffered intensely 
during infancy from eczema, which was with difficulty kept under control. When 
two years old she developed recurrent bronchitis with asthma of a most severe type, 
and she has had several attacks of spasmodic croup. Milk-fat, sugar, fruit-juice, 
or beef-juice in the case of this child produces an intense eczema. 

These cases all recovered under dietetic measures alone. 

Prognosis. — The prognosis is good, and the results are usually 
quite prompt following the right line of management. Relapses are 
not uncommon, however, because the treatment is so largely dietetic, 
and the best of people, when well, forget dietetic regulations more 
readily than anything else. 

Treatment. — Our first step in the management of eczema in a child 
is to learn all there is to know about the case. A full physical examina- 
tion is, therefore, made and the condition of the blood and urine is ascer- 
tained. The child is then given a regime of living suited to his con- 
dition. A diet schedule is furnished, the hours for rest and sleep and 
play are indicated, and if there is defective appetite or anemia, suitable 
added treatment is prescribed. One full bowel movement a day is 
required. It has been a matter of no little surprise to me to find the 
eczema gradually disappearing as a result of improvement in the child's 
general condition. Through the correction of digestive disorders and 
the estabHshment of right living, I have repeatedly seen cases of 
persistent eczema clear up entirely without other treatment. 

In a general way the suggestions laid down for the management of 
dehcate children (p. 122) may apply. In the diet I allow Uttle or no 
sugar. Milk, if used, is always skimmed. Butter, strawberries, 
tomatoes, and acid fruits are not allowed. The use of green vegetables 
is to be encouraged for the reason that they possess distinct thera- 
peutic value. An absolute salt-free diet is not insisted upon, but only 
sufficient salt is used to make the food barely palatable. Citrate of 
potash, referred to on p. 588, is equally useful in those cases. 



SEBORRHEA 595 

Contrary to the established behef I find arsenic of very little direct 
value, although in improving the general physical state of the patient 
it may be of service. I believe rhubarb and soda and cascara to be of 
much greater value. 

Local Treatment. — ^Local treatment may be of advantage in relieving 
the itching. In using skin applications for eczema in children it is 
necessary to exercise considerable care in not having the lotions or 
ointments too strong, in which event they will act as irritants and do 
harm. For the acute cases, in which there are much inflammation and 
itching, I frequently use a combination of zinc oxid ointment, U. S. P., 
and menthol, as follows: 

I^ Mentholis gr. x 

Ungt. zinci oxidi 5 j 

After the acute dermatitis has somewhat subsided, the following oint- 
ment may be used with advantage : 

I^ Acidi salicylic! gr. x 

Ungt. picis, U. S. P 5ss 

Ungt. aquae rosae q. s. ad 5ij 

This ointment should be used twice daily, the strength of the tar 
and the salicylic acid being increased if necessary as the case progresses. 
It is always well to begin with an apphcation of a reduced strength and 
to increase the strength later as the case may require. 

The ointment should be bound to the parts so as to completely 
cover the surfaces, thereby insuring the full benefit of the treatment 
and at the same time protecting the skin from further irritation by 
scratching. The case may respond very promptly, or it may be most 
obstinate and require several weeks of both dietetic and local treatment. 

Bathing. — When the skin is acutely involved, water should not be 
allowed to come in contact with it. Sterilized olive oil should be used 
for cleansing purposes. On uninvolved portions of the body, and in 
chronic, inactive cases, the soda or bran bath (p. 780) may be used. 

SEBORRHEA 

Seborrhea is usually classified as an eczema. It is due to excessive 
secretion and activity of the sebaceous glands, and is regarded by some 
observers simply as a derangement of function. By others it is believed 
to be due to a specific infection. 

Seborrhea Capitis (Milk Crust). — The form in which the condition 
is most frequently seen in children develops on the head, producing 
thick, dirty, yellow crusts, commonly known as "milk crust." The 
exudation consists of sebum, dirt, and desquamated epithelium. In 
mild cases the crusts may be isolated or combined in one large patch 
with several surrounding smaller areas. In other cases the exudation 
is thick and uniform, and covers the vertex of the head like a mask. 

Treatment. — The first step in the treatment is to remove the crusts. 



596 THE PRACTICE OF PEDIATRICS 

The hair should be cut very short. If only a few areas are involved, 
anointing the parts with vaselin several times daily will soften the 
exudate, so that it may be removed. If the crust is thick and extensive, 
it should be softened with sterilized olive oil, applied on gauze or old 
linen which is well saturated with the oil, and held in place by a cap of 
cheese-cloth. If the dressing is applied at bedtime the crusts may 
often be removed the following morning. In cases in which the exuda- 
tion has existed for a long time and is very hard, frequent fresh applica- 
tions of the oil for two or three days may be required to soften the crusts 
sufficiently for their removal without injury to the skin. When thor- 
oughly softened, they should be washed off with Castile soap and warm 
water. The underl;^ing skin will then usually be found to be reddish 
and slightly inflamed. To this should be applied an ointment of 
resorcin and vaselin, 15 grains to the ounce. The ointment should be 
spread on linen or lint and applied to the parts with the aid of the gauze 
cap. In all except the most aggravated cases this treatment, used only 
at night will be sufficient. In the severe cases a few additional ap- 
plications of the ointment during the day will usually be effective. 
A few days' treatment will often relieve the worst cases of seborrhoea 
capitis after the scalp has been freed from crusts. I have yet to see 
a case which will not respond when this treatment is properly carried 
out. It is to be remembered, however, that there is a tendency for 
the exudation to return. Mothers and nurses should be instructed to 
keep the ointment in the nursery for use upon the first appearance of 
the exudation. In children seborrheic eczema, according to my ob- 
servation, is comparatively unusual in other portions of the body, 
although by extension of the seborrhea of the scalp, the forehead and 
face may be involved. In these situations, also, resorcin is useful, but 
must be used in much weaker strength, ranging from 0.5 to 1 per cent. 

Seborrhea Intertrigo. — At rare intervals cases of intertrigo are 
encountered upon which no impression whatever is made by the 
methods of treatment suggested on p. 590. Several years ago Dr. 
George T. Elliott, of New York, called my attention to the fact that 
these cases were of seborrheic origin, and that a change from the 
ordinary treatment to that ordinarily used for seborrheic eczema would 
prove his contention. In the cases in question, and in those that I have 
since seen, the point made by him has been confirmed by the treatment. 
Cases of seborrhcea intertrigo are generally associated with seborrhea 
elsewhere, usually upon the head, and show erythema, a tendency 
to dryness of the skin, and desquamation. 

The treatment in this form of intertrigo consists in enforcing cleanli- 
ness and a proper diet, as mentioned under Intertrigo, p. 590. In 
addition to the usual means, from 0.5 to 1 per cent, of resorcin should be 
added to the zinc-oxid ointment which is used as a dressing. Euresol 
is here used with benefit in strength of 1 to 2 per cent, in unguentum 
aqua rosse. Seborrheic eczema, although not as difficult of manage- 
ment as the other forms of ezcema in children, nevertheless shows a 
great tendency to return, particularly in cases of low vitality. 



BED-SORES (dECUBITIS) 597 

PSORIASIS 

Psoriasis is an unusual disease in children, that is, unusual to 
pediatrists and practitioners. Bulkley has seen the disease in a 
baby four months old. Dermatologists are agreed that from 10 to 
15 per cent, of the cases that come under observation are under 10 
years of age. The disease is essentially chronic, occurring every 
winter and often disappearing with the advent of warm weather. 

The Lesions. — The lesions of psoriasis possess similar features which 
renders the diagnosis of little difficulty. The eruption first appears as 
brown flat papules with a tendency to desquamation. When the dis- 
ease comes under observation there is usually a series of areas of the 
papules which have coalesced and formed plaques which are covered 
with white or grayish scales. When the scales are forcibly removed 
small bleeding points may be seen. The lesions are very variable in 
number, size and location. In several of my patients they were situ- 
ated on the forehead at the margin of the hair. Here, thick infiltrated, 
desquamating crusts may form. 

The site of the eruption is usually on the extensor surfaces, often 
about the knees and elbows. There may be but two or three small 
areas or large portions of the skin surface may be involved. The nails 
and hands and palmar aspect of the soles of the feet are rarely 
affected. Staining of the skin at the site of the eruption, more or less 
persistent, remains. Symptoms other than the lesion are of little 
moment. There is usually some itching but usually not severe. 

Etiology. — The cause of psoriasis is not known. Bulkley claims 
it to be due to ''some constitutional error" — a break in metabolism. 

Treatment. — Treatment in my hands has been very unsatisfactory. 
The case may be reUeved by an exclusive vegetable diet, which means 
an absence of meat, fish, poultry "and eggs. Bulkley claims that cases 
may be cured and remain well when managed in this way. 



BED-SORES (DECUBITIS) 

During any illness productive of greatly disturbed nutrition or 
emaciation, such as cerebrospinal meningitis, typhoid fever, and em- 
pyema, constant pressure on the prominent bony parts interferes suf- 
ficiently with the circulation to cause destruction of the integument. 
The most frequent sites for decubitus in children are the sacrum, the 
heels, and the back of the head. 

The condition is best prevented by special care in maintaining 
cleanliness, by keeping the bed-linen smooth, and frequently changing 
the position of the patient, and by the free appHcation of any simple 
powder, such as equal parts of powdered zinc oxid and starch. 

Treatment. — The parts as they become sensitive and show redness 
should be bathed several times a day with alcohol. If this does not 
relieve the condition, the areas should be covered with diachylon 



598 



THE PRACTICE OF PEDIATRICS 



plaster so as to insure complete protection. The air-cushion or the 
water-bed may be necessary in any prolonged illness. 

When the back of the head is involved, the scalp should be shaved 
and the head allowed to lie in a home-made head-rest which is con- 
structed as follows (Fig. 81): A piece of fairly stiff wrapping paper, 
four inches wide, is twisted into a rope, of which a circle four to five 

inches in diameter is made 
by bringing the ends to- 
gether. The paper is then 
wrapped thickly with ab- 
sorbent cotton, which is in 
turn wrapped with a two- 
inch roller bandage. 

NEVUS (BIRTH-MARK) 

A nevus is a congenital 
new-formation in the skin. 
The growth may be pig- 
mentary or vascular. 

Etiology. — ^None of the 
various theories which have 
been advanced to account 
for the existence of nevi is 
well estabUshed. The fre- 
quent occurrence of vascular 
nevi in such regions as the 
has givQn rise to the belief 
by intra-uterine pressure. 




Head-rest to prevent bed-sores. 



back of the head and nape of the neck 

that these marks may be produced 

Virchow, however, emphasized the predilection of the growths for 

the embryonic fissures of the skin, where slight irritation would be 

capable of exciting anomalous vascular development. Females are 

more frequently affected than males. 

Symptomatology. — The pigmentary moles comprise ncevus pilusy a 
smooth, pigmented spot; ncevus pilosus, the hairy mole; ncevus verru- 
cosus, a raised warty growth; ncevus lipomatodes, which contains hy- 
pertrophied fat tissue; and ncevus linearis, which is usually unilateral, 
and frequently follows the distribution of cutaneous nerves. The 
moles may be brown or black, single or multiple, and are most common 
on the face, neck, and back. 

Vascular nevi range in character from small capillary angiomata to 
large, raised, pulsating tumors. One of the most disfiguring marks is 
the ncevus flammeus, or ''port- wine stain.'' This is a bright red or 
purple spot, of irregular outline and more or less uneven surface, com- 
monly found on the face, and covering an area which may be as large 
as the palm. The true vascular nevi all become pale under pressure, 
and, conversely, show the deepest color when the local blood-pressure is 
increased by such acts as crying or coughing. 

Prognosis. — Pigmentary moles rarely disappear spontaneously. 



NEVUS (birth-mark) 599 

The simpler forms of angioma may, however, occasionally undergo 
atrophy, or, on the contrary, increase in size over a Kmited period. 

Treatment. — Satisfactory results in treatment call for the exercise 
of considerable patience and skill. Many of the smaller capillary nevi 
may be made to disappear under the pressure produced by repeated 
applications of collodion. In more pronounced cases *' stippling" with 
nitric acid, electrolysis by multiple punctures, and exposure to the x- 
ray are methods of value. Jackson has emphasized particularly the 
value of freezing by liquid air or carbon dioxide snow. In suitable 
cases excision may be performed. Mention, however, should be made 
of the tragic results which have occasionally followed mechanical inter- 
ference with certain forms of mole. x\lthough it is possible that 
metastasis with general sarcomatosis is a phenomenon confined to 
adults, no one who has witnessed such an occurrence will advocate 
conservative surgery in the removal of pigmental growths. Unless 
excision can be thorough and complete, it should not be attempted. 



XV. DISEASES OF THE EAR 

EARACHE 

In every case of earache in an infant or young child the ear-drum 
should be examined. It may show intense congestion and bulging, 
requiring immediate incision, or only shght congestion about the pe- 
riphery of the drum and at the tip of the malleus. When the latter con- 
dition exists there are various means of relieving the pain, the most 
effectual probably being instillation into the ear of equal parts of a 
warm 4 per cent, solution of cocain and camphor-water, five drops of 
which are dropped into the ear, and repeated every half-hour if neces- 
sary, after which dry heat may be applied by the use of a hot-water 
bottle or a salt bag. I have frequently relieved severe attacks of ear- 
ache by means of a hot-water douche with one pint of water at 110°F., 
using a douche-bag or a fountain syringe. When the pain is not 
promptly relieved, the ear should be carefully watched, particularly 
if there is recurrent shooting pain, a throbbing sensation, or a feeling 
of fullness in the ear. In young children a rise in temperature associ- 
ated with earache is often indicative of an acute infectious process in 
the middle ear, and, in addition to the treatment suggested, the ear 
should frequently be examined, in order, if necessary, to insure early 
incision of the drum membrane. 

DEAFNESS 

Hearing is probably established in the newly born during the first 
two or three days of life. During the early months of life the hearing 
is very acute. Acquired deafness is not at all unusual, however, even 
in comparatively young children. Among its most frequent causes is 
an extension of an inflammation from the throat to the tubal mucous 
membrane. In diphtheria, in the exanthemata, in grip, in tonsillitis, 
and in many other ailments of early life there is an associated inflam- 
mation of the nasopharyngeal structures. Unless infection of the 
middle ear occurs, deafness is usually of a very temporary nature. 
Persistent deafness may be the result of enlarged tonsils, adenoids, or 
organized changes in the canal or in the middle ear. Among the most 
frequent causes of persistent deafness in children are adenoids, scarlet 
fever, and cerebrospinal meningitis. Congenital syphilis is an infre- 
quent cause of deafness. Response to treatment in this type is very 
satisfactory. Deafness at rare intervals follows an attack of mumps 
and is due to an involvement of the labyrinth. This condition calls 
for expert otologic treatment. 

Deaf children whose condition is not recognized are often accused 
of inattention and punished when they are slow in responding when 
spoken to. They make slow progress in school and are considered 
stupid. Many such children suffer from defective hearing of a pro- 
nounced type due often to enlarged tonsils and adenoids. 

600 



ACUTE OTITIS 601 

The management in these cases is to remove the adenoids and 
tonsils. When rehef is not afforded by operation, the child should be 
taken to an aurist for a careful examination as to the condition of the 
ears and the hearing capacity. 

ACUTE OTITIS 

Among the ailments of children few diseases are more frequently 
encountered than catarrhal or purulent otitis media. It occurs with 
great frequency in the hospital athreptic and in the institution infant. 
No age is exempt. I have seen otitis in infants of a few weeks of age. 
In well-nourished, \dgorous older children, it is, with but few excep- 
tions, a secondary infection. In poorly nourished athreptic infants it 
may occur without other evidence of illness. I have repeatedly found 
otitis of a low grade in athreptics who lacked the usual signs of fever, 
discharge, and bulging of the drum. In fact, in a considerable num- 
ber of cases the otitis was first discovered at autopsy. 

Types. — It is customary to divide the cases into two primary types: 
catarrhal and purulent. Such a grouping is hardly necessary, as most 
cases of the purulent type if seen sufficiently early present what are 
described as catarrhal symptoms. If the infection is not severe it sub- 
sides or responds to treatment. On the other hand, I have seen cases 
in which the ears had been frequently examined and in which the in- 
flammation was unquestionably purulent from the onset. 

Etiology. — Otitis is caused by the invasion of bacteria into the 
middle ear. 

In the atrophic young infant the low systemic resistance and the 
patulous Eustachian tube account for the ease with which the infec- 
tion reaches the middle ear and becomes operative. In older children 
adenoids and enlarged tonsils comprise the chief predisposing etiologic 
factors. Influenza, scarlet fever, measles, and diphtheria are the dis- 
eases most frequently accountable for otitis. It may follow any infec- 
tion of the nose or throat; thus we often see cases associated with or 
following rhinitis and tonsillitis. If a generous growth of adenoids 
exists in the vault of a throat affected by any one of the above diseases, 
the chances are more than even that suppurative otitis will develop. 

Among a series of 72 private cases which were reported several 
years ago, 3 were apparently primary in that the condition did not 
follow and was not connected with any previous abnormal state. One 
case followed German measles; 4, scarlet fever; 7, measles; and 58, 
influenza or catarrhal colds. 

Bacteriology. — In a series of 47 cases in which bacteriologic ex- 
aminations were made, the results were as follows: 

Streptococci in pure culture 13 

Staphylococci 11 

Streptococci, staphylococci, and pneumococci 12 

Streptococci, staphylococci, and pneumococci 6 

Staphylococci, pneumococci, and colon bacilli 1 

Streptococci and staphylococci 2 

Pneumococci 2 



602 THE PRACTICE OF PEDIATRICS 

The streptococcus supplies the most dangerous form of infection, 
and in this type not only are all the symptoms more severe, but there is 
much greater danger of mastoid involvement and secondary sinus 
thrombosis. 

Symptoms. — Among all the diseases of children none is probably 
so frequently overlooked as otitis. This is due to the fact that the 
practitioner invariably looks for pain as a symptom of the disease, and 
this has been the teaching of the books. In a search of many works on 
otology I find that the symptoms as laid down comprise almost ex- 
clusively the evidences of pain, — earache, — the pain being complained 
of by older children, or manifested in the very young by vigorous cry- 
ing, by tossing the head from side to side, by head-rolling, ear-tug- 
ging, crying out in sleep, disinchnation to rest the head on the affected 
side, or pain upon manipulation of the ear. In short, we have been 
taught that there is invariably some manifestation of pain referable 
to the ear or the adjacent structures in all cases of acute otitis in in- 
fants and young children. Such symptoms certainly exist in a mod- 
erate number of cases. 

The most interesting feature, however, in this series of 72 cases, was 
the absence of pain or localized tenderness on manipulation in 50 of 
the cases, or 69 per cent. Among those included in the pain group, 22 
in number, there were some cases which perhaps should not be so in- 
cluded, inasmuch as there were no signs of pain, as we generally expect 
to find it. The group included those who were very restless, who slept 
poorly, and who showed evidence of the relief which followed incision 
of the drum membrane, so that it was fair to assume that the source 
of the previous discomfort was the ear. Had we depended upon the 
signs of pain or local tenderness, in 50 of the cases a diagnosis of otitis 
at the time would have been impossible. Six were seen in consultation, 
because of the unexplained, continued fever. Nine had been treated 
by other physicians who had failed to discover the cause of the con- 
tinued fever. In none of these had ear involvement been suspected, 
because of the absence of pain and localized signs. 

Fever. — Among the 72 private cases already mentioned in well- 
nourished children, one symptom was present in all — fever. There 
was nothing particularly characteristic in the temperature range. In 
some there were the morning drop and the evening rise. In others 
the temperature variations were inconstant. With but few exceptions 
the otitis developed during convalescence from an acute process else- 
where, the ear involvement being suspected because of a persistent 
elevation of the temperature for which no other cause could be dis- 
covered. The fact that 58 of the cases, or 81.5 per cent., occurred 
with or followed non-specific inflammatory conditions of the upper 
respiratory tract, such as tonsillitis, grip, and catarrhal colds, empha- 
sizes the necessity for frequent aural examinations during or following 
such disorders, particularly when there is an elevation of the tempera- 
ture, which, in the absence of definite clinical signs, we are apt possibly 
to attribute to chronic grip, malaria, typhoid fever, or dentition. 



ACUTE OTITIS 603 

Course. — In a small number of cases perforation of the drum occurs. 
I have known the drum to rupture in one hour from the onset of the ear 
symptoms, and I have known the drum to remain intact with pus in the 
middle ear, to the best of my judgment, for ten weeks. In the average 
case, after a free opening of the drum, the discharge persists from ten 
to twenty days. In cases due to streptococcus infection the discharge 
is always more prolonged. 

Prognosis. — The prognosis is good if the drum is freely incised and 
kept open. A certain small percentage of cases which is difficult to 
determine develop mastoid disease, and a still smaller number become 
complicated by sinus thrombosis and jugular bulb involvement. 

The drum heals most readily. In numerous cases treated by, 
free incision I have found the drum absolutely normal in appearance 
within three or four weeks after the discharge ceased. 

Diagnosis. — Fever without apparent cause should always call for an 
examination of the ears. Earache is a symptom demanding like 
attention. 

Otoscopic examination settles the diagnosis and is the means of con- 
firming or refuting symptoms of unsolved fever or indefinite pain. 

Complications. — The most frequently encountered complication is 
mastoiditis caused by extension of the infective process to the mastoid 
cells. The mastoid antrum is separated from the middle ear by a very 
dehcate membrane. In many cases of acute otitis, probably in all cases 
showing prolonged discharge, the antrum is involved. If, within a 
minute or two after mopping out the canal, there is a free discharge into 
the canal, this affords strong presumptive evidence that the antrum is 
involved, as the small middle ear could not manufacture pus with such 
rapidity. 

Prolapse of the posterior superior wall is another sign of mastoid 
involvement. 

The continuation of high fever in spite of free aural discharge is 
indicative of mastoid abscess. 

If the mastoiditis exists, there may be swelling behind the ear or 
tenderness on firm pressure over the mastoid, particularly at the tip. 
Both of these symptoms — pain upon pressure and swelling — may fail 
us, and their absence is not to be considered in any way conclusive evi- 
dence against the presence of mastoid disease. There is no doubt but 
that in many cases of prolonged aural discharge the antrum is diseased 
and supplies a large part of the pus. The deeper cells in the bone 
escape infection. 

Treatment. — A small percentage of the catarrhal cases in which 
there is congestion of the drum without bulging, will subside under irri- 
gation at two-hour intervals with normal salt solution at 110°F. One 
pint should be used. A fountain-syringe placed at an elevation of three 
feet above the child's head affords the best means of irrigation. 

Regardless of the age or condition, a bulging drum in the presence of 
fever calls for incision. No harm is done to the ear by the free in- 
cision properly made, while much harm as the result of chronic 



604 THE PRACTICE OF PEDIATRICS 

otitis media and mastoid disease may occur when the incision is 
delayed. 

Operative. — Every practitioner who has children as his patients 
should be sufficiently familiar with the landmarks of the normal drum 
membrane at the various ages of early life to differentiate the normal 
from the abnormal. In the routine examination of the child, in all 
conditions associated with angina or fever, the ear should be included. 
In quite young babies an otoscopic examination may show a dull, 
whitish-appearing drum membrane which, on a superficial examination 
of the case, might be ignored. In all cases, particularly at this age, 
when the drum landmarks are indistinct, a cotton-pointed probe 
should be brushed over the surface, thus removing the epithelial scales 
which may have lodged there, then perhaps a congested, bulging 
membrane may be revealed. 

Conditions or appearances of the drum membrane which require 
incision are often difficult of recognition by those not skilled in otoscopy. 
When the drum is bulging, deeply congested in appearance, with 
landmarks indistinct, an incision is necessary, and should be made in 
the posterior quadrant, beginning low down and extending upward 
through Shrapnell's membrane. When also there is congestion of 
the drum membrane over the tubal entrance, and when the congestion 
extends toward the periphery, producing indistinct landmarks with- 
out bulging, incision is indicated. 

Post-operative. — The after-treatment following incision consists in 
syringing the ear at three-hour intervals with 8 ounces of a 1 : 10,000 
solution of bichlorid of mercury for three or four days, after which the 
syringing may usually be practised at intervals of from four to five hours 
until the drum closes. In very young infants if the bichlorid causes a 
dermatitis at the meatus, it is well to change to a sterile normal salt 
solution, using the same quantity of fluid. In those cases in which 
only serum is present at the time of operation, closure in ten days may 
be expected; if, however, pus is present, from two to three weeks will 
be required. A sudden stopping of the discharge usually means that 
the opening in the drum is closed, either through plugging with 
thick pus or because of too early healing. In either event a reestab- 
lishment of the discharge is required by removing the obstruction or 
by reincision. The chief factors in prolonging the discharge are ade- 
noids and a lowered state of physical resistance. After the syringing, 
the ear should be carefully dried with absorbent cotton. For purposes 
of syringing a one-ounce hard-rubber ear syringe with soft-rubber 
tip answers best. If this is not obtainable, a douche-bag, at an ele- 
vation of not more than three feet above the patient 's head, may be 
used. The douche-bag sometimes answers better for those who are 
unskilled, or a soft-rubber bulb syringe of a capacity of one or two ounces 
may be used. The small, double-current ear-irrigator may be used with 
advantage for the reason that it largely prevents wetting the patient. 
During treatment by any of these methods the child rests on his 
back with his hands pinned to his side by means of a large bath towel, 



CHRONIC SITPPURATIVE OTITIS 605 

while a pus basin is held under the ear to catch the flow (Fig. 82) . If 
the nurse can have an assistant, the upright position may be used. 

Delayed Resolution. — In a certain number of cases resolution is 
delayed and the discharge continues. In such cases a decided aid is 
furnished by the use of stimulating and disinfectant instillations. 
After the last syringing for the day the canal should be dried by the 
use of a wick of absorbent cotton. Five drops of the following 
solution are then to be instilled into the ear: 

I^ Pulv. acidi borici gr. xxv 

Spts. vini rect., 

Aquae aa§ss 




Fig. 82. — Syringing the ear. 

McKernon, of New York, advises the use of a 15 per cent, solution 
of argyrol in a similar manner. 

CHRONIC SUPPURATIVE OTITIS 

Not infrequently cases come under our care in which there is a 
purulent discharge from the ears, often most offensive, with a history 
that the discharge has followed measles, scarlet fever, or grip, and has 
continued for weeks or months. Examination may show a perforation 
of the upper portion of the drum, through which there is a free dis- 
charge, which, however, on account of the site of the perforation, is not 
sufficient to drain completely the middle-ear cavity. In other in- 
stances the examination may disclose only a small perforation, too small 
for effective drainage. 



606 THE PRACTICE OF PEDIATRICS 

Treatment. — In either case incision should be made and free drain- 
age estabhshed. The ear should then be syringed (Fig. 82) at laast 
three times a day with a 1 : 10,000 bichlorid solution. The instillation 
of a solution of argyrol and boric acid (see p. 605) may also be used with 
decided advantage. In cases of chronic suppurative otitis it is well to 
examine for adenoids, as these growths in the nasopharyngeal vault 
help to keep up ear-discharge indefinitely. The presence of dead bone 
and granulations is also to be considered in the chronic suppurative 
cases. When the presence of dead bone or granulations is established, 
the condition calls for radical procedures by a skilled otologist in order 
to avoid mastoid and intracranial complications. 

In long-standing cases, especially those due to staphylococcus in- 
fection, the administration of an autogenous vaccine sometimes is 
attended with excellent results. 

MASTOIDITIS 

Because of the ease with which pus may enter the mastoid antrum 
the complication of mastoiditis is of frequent occurrence in acute aural 
diseases. Streptococcal infection of the middle ear predisposes to mas- 
toid involvement. Delay in incising the drum and establishing free 
drainage in acute otitis is also a factor in not a few cases. Finally, as 
an underlying cause of mastoiditis should be mentioned the child's 
lack of general resistance to bacterial infections. 

Symptoms. — Mastoid disease may be looked for in all cases in which 
an elevation of the temperature continues in spite of free discharge 
through a well-opened drum. Tenderness on pressure is a valuable 
sign, but its absence does not preclude mastoiditis. 

Prolapse of the posterior superior wall and the rapid appearance of 
pus in the canal after thorough cleaning are to be looked upon as most 
important symptoms. 

When there is tumefaction and swelling of the soft parts behind 
the ear, called perimastoiditis, the mastoid cells and antrum will almost 
invariably be found involved. In about 10 per cent, of the cases both 
mastoids will be involved. 

Complications. — The complications are sinus thrombosis, jugular 
involvement, septic meningitis, and pyemia. I have seen all these 
most serious complications in not a few cases, and have cause to re- 
gard the presence of pus in the mastoid cells or even in the middle ear 
in children as a matter of serious import. 

Treatment. — The radical operation, and that early, is the only 
treatment for the condition. Children have unquestionably recovered 
from mastoid disease without operation, but expectant procedures are 
fraught with great danger and should not be countenanced if the child 
is in condition to admit of operation. 

SINUS THROMBOSIS 

In a small percentage of cases of mastoiditis there is a secondary 
infection of the lateral sinus. 



SINUS THROMBOSIS 607 

Symptoms. — Sinus involvement will usually be indicated by rapid 
and wide variations in the temperature. The rise is very sudden, and 
may reach 106° F. I have seen a rise of 10 degrees in two hours; the 
fall may be correspondingly rapid, and a peculiarity of the temperature 
phenomena in sinus disease is the extent of the fall. I have repeat- 
edly known the fever to drop to 96°F. 

A confusing and misleading circumstance in these cases may be the 
absence of signs of great prostration. When the temperature is high, 
the child appears very ill ; when the fever subsides, the patient brightens, 
perhaps plays, and is interested in his surroundings. It is difficult to 
reconcile the patient's demeanor with so grave a disease. The mis- 
leading behavior, in my observation, has been the occasion of delaying 
operative measures until such means proved of no avail. 

Leukocytosis and a high polynu clear count are usually present. I 
had one case, however, in which the polynucleosis was not above 60 
per cent. 

Bacteremia is usually present. Its absence, however, does not pre- 
clude sinus disease. 

Treatment. — The treatment is the radical operation, with resection, 
if necessary, of the jugular vein. 



XVL THE TRANSMISSIBLE DISEASES 

In this division of diseases are included those which may be trans- 
mitted from the diseased to the unprotected individual. 

Diseases Which May be Transmitted Through Association. — Syphilis, 
diphtheria, gonorrhea, stomatitis, tuberculosis, pneumonia, scarlet 
fever, measles, German measles, mumps, smallpox, chicken-pox, per- 
tussis, poliomyelitis, meningitis, acute cerebrospinal meningitis, plague, 
typhus, influenza. 

Diseases Which May he Transmitted Through an Intermediary. — • 
Gonorrhea, typhoid fever, malaria, yellow fever, tuberculosis, cholera, 
plague, stomatitis, typhoid fever, scarlet fever, diphtheria, measles, 
chicken-pox. pertussis, syphilis, typhus and poliomyelitis. 

It will be observed that some of the foregoing diseases are trans- 
missible in more than one way. 

Syphilis, in addition to being transmissible through association, 
is transmissible by inheritance. 

Gonorrhea is transmissible through association and through inter- 
mediary objects. That the latter mode of conveyance is common is 
absolutely proved by the spread of the disease in institutions and hos- 
pitals, through the use of the thermometer or at the hands of attendants. 

Among the diseases grouped as transmissible through association, 
in which such transmission is eminently a feature of the disease, are 
those that usually have been designated as contagious, e. g., scarlet 
fever, diphtheria, measles, German measles, mumps, smallpox, chicken- 
pox, pertussis and poliomyelitis. 

Among the diseases transmissible by intermediary means, gonor- 
rhea has been referred to. 

Typhoid fever is usually water-borne or food-borne by flies. Ma- 
laria and yellow fever are transmitted by the mosquito. 

Cholera is usually a water-borne disease. 

Plague may be transmitted through any intermediary which has 
been in contact with the infected subject. 

Stomatitis, a comparatively insignificant disease, may be trans- 
mitted through nipples, pacifiers, or toys that have been in the mouth. 

There is quite an unanimity of opinion that scarlet fever, diphthe- 
ria, measles, chicken-pox, mumps, and smallpox may be transmitted 
from the diseased to the unprotected individual through the agency of 
an intermediary person or object. My own observation corroborates 
this view. At the same time I am sure that such transmission is less 
frequent than is generally supposed. 

The usual means is through association with an individual who has 
the disease, perhaps in so mild a manner that it has not been recognized. 

608 



VARICELLA (CHICKEN-POX) 609 

This is particularly the case with diphtheria, scarlet-fever and polio- 
myelitis. 

These diseases, viz., scarlet fever, diphtheria, measles, chicken-pox, 
pertussis, German measles, poliomyehtis and mumps have another 
feature in common. They may be extremely severe, or so mild that the 
case is not recognized, and the patient associates as usual with his fel- 
lows. It is to these mild cases that the spread of the disease is due 
rather than to a transference of the contagium through unusual 
channels. 

It has been estimated that 1 per cent, of children in cities have 
viable diphtheria bacilli in their throats. 

Scarlet fever, because of the possible variation of its course and the 
indefinite rash, is overlooked more frequently than any other of the 
diseases of this class. It is not at all unusual for school inspectors to 
find children, with active scarlet-fever desquamation, in attendance at 
schools. The abortive non-paralytic cases of poliomyelitis are 
unquestionably the chief agency in the transmission of this disease. 

I have seen a case of chicken-pox in which there were but five 
vesicles without other sign of illness, and patients with unquestionable 
pertussis who never whooped. 

The last-mentioned group are referred to in the chapters which 
immediately follow. For reasons of greater convenience some of the 
transmissible diseases are described elsewhere. 

CARE TO BE EXERCISED BY THE PHYSICIAN IN VISITING INFECTIOUS 
AND CONTAGIOUS DISEASES 

Physicians in attendance upon contagious diseases, particularly 
diphtheria and scarlet fever, should exercise reasonable care in their 
association with other patients. The coat should be removed and 
shirt-sleeves turned up to the elbows. A gown, or a sheet suitably 
adjusted with safety pins, should protect the clothing. 

After leaving the patient the physician should wash his hands with 
hot water and soap. 

VARICELLA (CHICKEN-POX) 

Chicken-pox belongs to the transmissible diseases, and is usually 
transmitted by association contact, rarely through an intermediary. 
The contagium of varicella is present in the fluid contents of the eruptive 
vesicles, and also in the crusts resulting from the drying of the vesicular 
contents. Consequently the period of transmissible infection persists 
as long as any crusts remain on the skin. The exact nature of the 
specific etiologic factor of this disease is still unknown. 

Incubation. — The period of incubation is rarely less than eighteen 
days or longer than twenty-five days. In the majority of my cases it 
has ranged between twenty and twenty-five days. 

Symptoms. — Prodromal symptoms are rarely of sufficient severity 
to warrant complaint or give evidence of illness on the part of the 
39 



610 THE PRACTICE OF PEDIATRICS 

child. In severe cases there may be slight temperature and muscle 
soreness. 

The temperature rarely goes above 102°F., usually not over 100°F. 

The Rash. — The eruption is usually the first important sign of the 
disease. The back and abdomen are the sites ordinarily involved early. 
The rash may appear on any portion of the body. It occurs abun- 
dantly on the scalp. Usually there are a few spots in the mouth. 

Character of Rash. — Not infrequently from the onset it is distinctly 
vesicular, without any associated skin inflammation, resembling drops 
of water that may have been sprinkled carelessly over the skin surface. 
More frequently the rash consists of macules, then papules, and later 
vesicles resting on well-defined red areolse. At first the vesicles con- 
tain clear fluid and vary in size from mere points, scarcely discernible 




Fig. 83. — Deep ulceration in case of dermatitis gangrenosa infantum following 

chicken-pox. 

to the naked eye, to lesions J-^ inch in diameter. In a few hours the 
serum becomes cloudy and purulent. In from twenty-four to seventy- 
two hours the fluid is absorbed, leaving the erupted area slightly um- 
biUcated, so that on further drying this forms a crust or scab. These 
crusts fall off in from one to three weeks, leaving a distinctly reddish 
skin area, at the site of which there is sometimes a temporary scar. 
The rash varies greatly in its intensity. Most of the lesions do not 
go through the characteristic stage just mentioned, and many do not 
go beyond the papular stage. All stages of the eruption may be seen 
at one time in any well-marked case, for the reason that the rash ap- 
pears in successive crops, of which there are usually three, although 
there may be more. The first crop may be in the scabbing stage when 
the third or a later crop appears. The amount of rash is extremely 
variable. In one of my cases there were but three vesicles. In three 
others, all institution cases, so severe and extensive was the rash that it 
resulted in a gangrenous dermatitis consisting of clearly punched-out 
ulcers. The gangrenous area coalesced, with destruction of large 
areas of the skin surface. These three cases were all fatal. 

Complications. — Erysipelas was a complication in two cases; gan- 
grenous dermatitis in three. Nephritis, although rare, may develop. 
One of the worst cases of acute glomerular nephritis which I have had 
occasion to treat occurred as a sequel of chicken-pox. Furunculosis 



MUMPS 611 

due to infection by scratching is a quite frequent complication in chil- 
dren's asylums. 

Duration. — The duration of an attack, from the beginning of the 
period of eruption until the skin clears, is about three weeks, but may 
be longer. In mild cases the skin may become clear in two weeks. 

Quarantine. — The child should be kept in quarantine and not al- 
lowed to come in contact with unprotected children until three weeks 
have elapsed, or until the skin is free from crusts. 

Prognosis. — The prognosis is good. It is very unusual for the 
most delicate child to succumb to the disease. The institution infants 
who developed gangrenous dermatitis (Fig. 83) were the only fatal 
cases to come under my observation. 

Treatment. — Chicken-pox is a disease for which very little treat- 
ment is required. During the eruptive period, and until the period of 
vesiculation is passed and the crusts have formed, the child should be 
kept in bed. 

During the stage of active eruption the tub-bath should be omitted. 
Instead, gentle sponging with a tepid solution of boric acid — two heap- 
ing tablespoonfuls of boric acid to one-half gallon of boiled water — will 
answer the purpose of cleanliness for a few days. After the daily 
sponging, and several times during the day, the areas affected should be 
anointed with a boric-acid ointment made with cold-cream as follows: 

I^ Mentholis gr. x 

Pulveris acidi borici gr. c 

Unguenti aquae rosae §ij 

The ointment effectually relieves the itching, and doubtless is of 
value in preventing local skin infection through scratching. An equally 
effective remedy, but one less agreeable for domestic use, is a lotion of 
5 per cent, ichthyol and sterilized olive oil. This is to be applied to 
the entire body twice daily after the bath. Objections to its use are 
the odor and the staining of the clothing and bed-linen. Permanent 
scars at the site of the vesicles are so rarely seen that no special precau- 
tions are required on this account. 

MUMPS (EPIDEMIC OR SPECIFIC PAROTITIS) 

Mumps is a specific infection of the parotid glands. 

Cocci have been isolated from the inflamed parotid gland in cases 
of mumps, but their specificity has never been proved. More recent 
studies point to a filtrate virus, as the probable cause of the disease 
(Wollstein). The exact nature of the virus has not yet been deter- 
mined. 

Mumps affects chiefly the runabout and school-children. Infants 
and very young children rarely have the disease. 

Transmission. — The disease may be conveyed by direct contact 
or through intermediary individuals, books, toys, or clothing. 

Incubation. — The period of incubation is long — from three to four 
weeks. 



612 THE PRACTICE OF PEDIATRICS 

Duration. — The duration of the disease from the commencement 
of the swelHng until it has completely subsided is from ten days to 
two weeks. 

Quarantine should be maintained until the swelling has entirely 
subsided. 

Pathology. — As the great majority of cases recover, it has been 
difficult to study the pathology of the disease. The pathologic changes 
that are known to occur are ordinarily hmited to the salivary glands. 
There is edema and cellular infiltration of the connective tissue around 
the ducts and between the acini, while the glandular epithelium is 
often swollen and cloudy. The infiltration is most marked around 
the secretion ducts. 

When mumps affects the testis, the inflammation assumes a paren- 
chymatous form, and when the epithelial degeneration in the tubules 
is severe, atrophic changes in this gland may follow. Occasionally the 
orchitis is accompanied by urethritis, edema of the scrotum, and 
inguinal adenitis. 

Ovaritis and mastitis complicating mumps have been observed. 
Acute pancreatitis has been reported. 

Symptoms. — Usually one gland is affected at first, and the gland 
first affected is usually the one most prominently involved, the 
second gland rarely reaching the size of the first and subsiding much 
sooner. In some cases, three or four days intervene before the second 
gland shows the characteristic swelling. The submaxillary glands may 
be involved in the process, but usually escape. In one of my patients 
the submaxillary glands alone were involved. In a very recent case 
in a child three years of age both parotids and submaxillary glands 
and the sublingual gland showed massive involvement. 

Involvement of other salivary glands than the parotid is more fre- 
quent during cold weather. 

There may be prodromal symptoms of fever and languor. Diffi- 
culty is experienced by the patient in working the jaws. Not infre- 
quently there are sharp neuralgic pains and pains referred to the ear. 
An elevation of the temperature is usual during the acute stage, al- 
though this may not exceed 100°F. In most instances it will not ex- 
ceed 102°F. If the glands are involved at two or three days' interval, 
there may be two distinct rises in temperature. The temperature is 
rarely sufficiently high to demand special streatment. 

Diagnosis and Differential Diagnosis. — The patient presents a 
characteristic picture, the face taking on a rotund, rather ludicrous 
appearance, produced by no other malady. Acute adenitis of the 
lymphatic glands at the angle of the jaw is most frequently mistaken 
for mumps. Mumps, on the other hand, is not mistaken for adenitis. 

In history taking, not infrequently one is told that the child has had 
two or three attacks of mumps, which means that the child has had 
perhaps one attack of mumps and several of acute adenitis. In mumps 
the swelling, by involving the parotid, which it will be remembered is 
in front of and below the ear (Fig. 84), displaces the lobe upward and 



MUMPS 



613 



outward and completely fills the depression posterior to the lobe. In 
adenitis (Fig. 48) there is usually a well-marked depression between the 
sweUing and the adjoining parotid. 

Complications. — Complications in mumps are exceedingly rare be- 
fore puberty. Orchitis may occur in boys and ovaritis in girls, but only 
very exceptionally if the patient is kept in bed. Infection of the paro- 
tid other than that produced by the specific poison of mumps is ex- 
tremely rare. Abscess as a complication due to a mixed infection has 
been reported. Nephritis is an occasional compUcation. I have seen 
one such case in a boy two years of age. I have never observed corn- 




Fig. 84. — Mumps. 



plicating pericarditis, endocarditis, or pancreatitis, although such com- 
plications have been reported. 

Prognosis. — The prognosis is good. I have never known a second 
attack, a relapse, or a death from the disease. 

Treatment. — During an attack the child should be kept in bed until 
the temperature is normal, and should remain in the house until the 
swelHng has entirely subsided. He should receive a reduced diet of 
broths, gruels, and milk, as in any illness with fever. Fruits and acids 
should not be given because of the discomfort they occasion. Unless 
the bowels move daily without assistance, citrate of magnesia or a 
Seidhtz powder should be given. 

Warm applications at times relieve the pressure and discomfort. 
Flannel moistened with warm camphorated oil and bound to the parts 
has been acceptable to many patients. 



614 THE PRACTICE OF PEDIATRICS 

WHOOPING-COUGH (PERTUSSIS) 

As an infectious disease of importance, pertussis may be classed 
with diphtheria and scarlet fever. It is probably the cause of more 
deaths today than is any other infectious disease. It does not kill 
directly through the means of a specific poison, as do diphtheria and 
scarlatina, but on account of its prolonged course and its many compli- 
cations is equally effective as a life-destroyer. 

History. — Whooping-cough has existed from early times, under 
such names as 'Hussis perennis," 'Hussis infantum," ''chink cough," 
'' chine-cough," and ''king's cough." In a treatise published in 1773 
William Butter, of Edinburgh, aptly describes "kinkcough" as "a 
quick and numerous succession of violent, short coughs followed by a 
long, strait, and generally shrill inspiration, which coughs and inspira- 
tion are repeated without intermission for many seconds or often some 
minutes, and often terminate in the vomiting of phlegm." Robert 
Watt, writing in 1813, states that "next to the small-pox formerly, and 
the measles now, chincough is the most fatal disease to which children 
are liable." 

The seat of the affection was variously placed by the early writers 
in the nervous system, in the digestive organs, and in different portions 
of the respiratory tract. Butter believed that "miasms generated in 
the guts, act on the nerves" and "increase irritability." Further 
information is proffered in statements that "measles render the kink- 
cough very dangerous;" "smallpox either cures or palliates;" and that 
*' hemlock cures the kinkcough in a week." A critic of the hemlock 
therapy ironically recalls that "the flesh of fryed mice . . . has 
been in vogue as a specific." Certain it is that even in very recent 
years no disease has been treated by remedies of wider diversity. 
Partial explanation of this fact undoubtedly rests upon the frequent 
association of whooping-cough with other diseases, as well as upon the 
varying therapeutic requirements of its more common complications. 

Bacteriology. — The bacillus described by Bordet and Gengou in 
1906 is at present generally accepted as the probable cause of pertussis. 
The bacillus is a short, ovoid, polex, regular, non-motile rod, which 
does not stain by Gram's method. It is best isolated upon plates of 
potato-agar mixed with rabbit's blood, as described by Bordet and 
Gengou, but later generations grow readily upon plain agar. The 
bacillus is present in the sputum in enormous numbers, and almost in 
pure cultures on the first two or three days after the onset of the whoop, 
and it may be found several days before the spasmodic stage begins 
(Wollstein). At the end of the first week of this stage, however, other 
bacteria, such as pneumococci and staphylococci, have usually become 
so numerous that isolation of the bacillus is impossible. Agglutina- 
tion reactions with the patient's serum are irregular and unsatisfactory. 
Complement fixation tests have been reported positive, but they are 
not regularly so. 

Jochmann and Krause found the influenza bacillus in the sputum of 
pertussis patients in 100 per cent, of the cases they studied. It may be 



WHOOPING-COUGH (PERTUSSIs) 615 

present there before the whoop develops (Wollstein), and it may remain 
for a period of six months after the attack has ceased (Davis), thus 
making of these patients influenza-bacillus carriers. 

In children who have died during the spasmodic stage of an attack 
of pertussis the Bordet-Gengou bacillus has been found in the heart's 
blood and also in the lungs, where Bacillus influenzae is usually present 
as well. 

Pathology. — There is very little characteristic pathologic change in 
pertussis. There is an inflammation and infiltration of the mucous 
membrane of the larynx and upper trachea, which is doubtless the seat 
of the specific infection. Mallory claims that the specific lesion is the 
presence of B. pertussis between the cilia of the epithelial cells of the 
trachea and bronchi. 

Transmission. — Transmission, as with most of the communicable 
diseases, is by means of direct contact. That pertussis may be con- 
veyed through the medium of clothing, a book, a toy, or a second person 
is exceedingly doubtful. 

Extreme youth offers no protection, as in the case of scarlet fever 
or diphtheria. 

Infective Period. — The disease may be transmitted from the begin- 
ning of the catarrhal stage. The duration of the period of infection is 
not known. It probably continues in the average case until the child 
ceases to whoop. 

When pertussis breaks out in a school or in an institution for chil- 
dren, prevention of an epidemic is practically impossible, because the 
disease is infectious during the early catarrhal stage, which lasts from 
one to two weeks. During this time the only symptom is a cough and 
perhaps a slight degree of bronchitis, such as exists with a common cold. 

Susceptibility. — The previous state of health appears to exert no 
influence upon the patient's susceptibility. The strong and the deli- 
cate are alike predisposed to infection. The very young and the adult 
are less liable to take the disease than are children between the fourth 
month and the third year. This period is the most susceptible time of 
life. Cases have been reported in children one week old. Any other 
concurrent infectious disease exerts no influence upon the course of the 
pertussis. The theory has been advanced that the advent of diph- 
theria or scarlet fever during an attack of pertussis shortened and 
modified the course of the disease. My experience does not corrobo- 
rate this behef . Other affections which occur during an attack simply 
increase the burden to be borne by the patient. The largest number of 
cases develop during the warmer months — from May to November. 
This circumstance may be accounted for in part by the fact that during 
the warm period of the year the infected child comes more frequently 
in contact with unprotected neighbors. The same circumstance, how- 
ever, tends to disprove that catarrhal affections of the respiratory tract 
predispose to the disease, since respiratory affections in the young dur- 
ing the warmer months are notably rare. The normal healthy mucous 
membrane offers no greater resistance to pertussis than does that which 



616 THE PRACTICE OF PEDIATRICS 

is affected by disease. In the early stages of pertussis there is not 
simply a bronchitis, but a catarrhal process due to a specific infection. 

Interesting observations relative to susceptibility to measles and 
pertussis were made by Biedert. After a lapse of sixteen years both 
these diseases broke out in a German village at about the same time. 
There were 401 children in the village under fourteen years of age. 
These children had never been far from home, and not one of them 
had had either measles or pertussis. Of this number, 344 became ill 
with measles and 366 with pertussis, 340 having both diseases at once. 
The susceptibility of these unprotected children to pertussis was, 
therefore, 95.5 per cent.; to measles, 85.8 per cent. Of those who 
escaped pertussis, 7 were under five years of age, 4 between five and 
ten years, and 9 between ten and fourteen years. 

Incubation. — The period of incubation is difficult to determine. 
It seems to range from seven to fourteen days. 

Symptoms. — At the outset the cough may be short, hard, and of a 
paroxysmal nature. Usually, however, the cough is in no way char- 
acteristic and does not differ from that which accompanies bronchitis 
or tracheitis. Instead of improving under treatment, this symptom 
becomes more severe and more frequent. The child coughs more at 
night, usually, than during the day. In a week or ten days, rarely less 
than a week, the characteristic whoop occurs. 

Complications. — The complications of pertussis are many, and 
account for the fact that the disease is so destructive to life. The 
mortality of pertussis is generally estimated at 4 to 6 per cent. That it 
is actually much higher is well known to every one who has seen much of 
the disease. The most fatal complication in winter is bronchopneu- 
monia; in summer, gastro-enteric disease. Convulsions are not an 
infrequent complication, and may be fatal. Malnutrition often follows 
a severe attack in delicate, bottle-fed children, thus paving the way for 
intercurrent disease. Tuberculosis not infrequently follows a pro- 
longed attack of pertussis. Blindness, deafness, and motor disturb- 
ances have all been observed during attacks of pertussis, and have been 
followed by complete recovery. These cases may be explained as 
follows: During a severe paroxysm the cerebral circulation is greatly 
disturbed, and as a result of a moderate congestion or venous hyperemia, 
there is a disturbance of nutrition in certain portions of the brain. 
On the cessation of the paroxysm these symptoms all disappear. 

Diagnosis. — The diagnosis of pertussis is most difficult in the early 
stages, before the whoop or convulsive paroxysm develops. Even a 
spasmodic cough does not always mean a developing pertussis. 

In rachitic children, and in those in whom the nervous element is 
prominent, the cough of an ordinary cold is often of a decidedly 
paroxysmal character, especially when there is an acute or subacute 
laryngitis. 

The cough, however, if more troublesome at night, favors a diagno- 
sis of pertussis. If the diagnosis is correct, the cough grows steadily 
worse and resists the usual treatment of colds. 



WHOOPING-COUGH (PERTUSSIs) 617 

The mild cases are also difficult of diagnosis. 

Illustrative Cases. — Recently two patients, aged eight and ten years respec- 
tively, went through an attack of pertussis with but two or three severe paroxysmal 
coughing attacks. 

Two other cases seen in private practice also show how mild may be the 
course. The patients, brother and sister, aged six and eight years respectively, 
commenced coughing about ten days after exposure. The cough was paroxysmal, 
with from three to five seizures in twenty-four hours. The boy whooped only three 
times during the entire course of the disease; the girl did not whoop at all. Vomit- 
ing never occurred with a paroxysm. Both patients coughed for six weeks. They 
had neither adenoids nor bronchitis. 

Often the very young and the very delicate do not whoop, even dur- 
ing a severe attack. Among the severe cases convulsions and hemor- 
rhage from the nose, ears, and eyes are seen from time to time. A very 
severe seizure in a girl nine months old was followed by small extra- 
vasations of blood into the skin of the entire body. 

Differential Diagnosis. — In all cases of severe cough of uncertain 
origin the nasopharyngeal vault must be examined for adenoid growths. 
In young children this can be properly done only by the use of the index- 
finger. 

The presence of a persistent cough with a paroxysmal tendency, in 
the absence of local respiratory irritation of any nature, is very sug- 
gestive in a suspected case. 

Prognosis. — Pertussis in children under eighteen months of age 
must ever be regarded in a serious light. Delicate and rachitic chil- 
dren should be carefully guarded against the disease. Bronchopneu- 
monia and gastro-enteric troubles are the most frequent complications 
among this class of children. The majority of healthy children 
over eighteen months of age bear whooping cough without great 
inconvenience. 

Treatment. — A wide experience in the use of pertussis vaccine places 
this method of treatment in the front rank of the remedies. As 
a single remedial measure the vaccine furnished better results as regards 
relieving the symptoms and shortening the disease than any other 
form of treatment. As with all new therapeutic measures one must 
learn by observation in a considerable number of cases how to apply 
the remedy. Qur best results have been obtained where the following 
dosage and procedure was carried out. Four injections were given 
with one day intervening between each as follows: 

1st = 1 Billion 
2d = 2 Bilhon 
3d = 4 Bilhon 
4th = 6 Billion 

There were 29 cases treated in private practice. 

In 2 cases the results were entirely negative, no apparent effects 
were noticeable. In these we resorted to the use of drugs. In 
27 cases the results were very striking. A complete cessation of the 
paroxysms resulted in from one to four weeks. A decided improve- 
ment was often noticed after the second or third injection. If after 



618 THE PRACTICE OF PEDIATRICS 

the above method there is Uttle or no improvement or if there is a 
recurrence of the paroxysms two more injections of 6 BiUion each 
are given at an interval of forty-eight hours. 

Drug Treatment. — The use of drugs in whooping cough has always 
been more or less of a disappointment. We have been able in most 
cases to supply a certain amount of relief. The illness may be made 
easier for the patient to bear, which of course is important. By the 
use of drugs the paroxysms may be lessened in number and severity. 

My best results have been obtained in the use of antipyrin and 
bromid of soda in combination as follows: 

For a child eight months of age, K grain of antipyrin with 2 grains 
of bromid of soda are given at two-hour intervals — 6 doses in twenty- 
four hours ; for a child of fifteen months, 1 grain of antipyrin and 23-^ 
grains of bromid of soda at two-hour intervals — 6 doses in twenty-four 
hours; from the fourth to the eighth year, 2 grains of antipyrin and 
5 grains of bromid of soda at two-hour intervals — 6 doses in twenty- 
four hours. 

Quinin has been used in a large number of cases in both private and 
outpatient work. I find that great benefit can be derived from its use 
if a large amount can be given. Its administration, however, is at- 
tended with difficulties. Twelve to twenty grains in twenty-four 
hours are required for pronounced results in children from two or six 
years of age, and the administration of such a large amount is not 
favorably received by many parents. Again, our inability to make the 
the drug palatable is a serious drawback for any age, and almost ex- 
cludes its use in the very young; furthermore, in the very young 
and delicate quinin may derange the stomach and produce vomiting. 
The best form of solution to use is that of bisulphate in Yerberzine 
(Lilly). In older children, when quinin can be given in sufficient 
quantities in capsules, the decrease in the number and severity of the 
paroxysms is sometimes surprising. 

Codein is to be used in the most severe forms of pertussis, when 
other means fail to reUeve the patient. One of the most troublesome 
features of the disease — in fact, a dangerous feature — is the wakeful- 
ness at night caused by repeated attacks of coughing and vomiting. 
When the child cannot sleep, I give codein independent of the other 
treatment, whatever it may be. For a patient five years of age J^ 
grain is given at bedtime and repeated during the night whenever the 
paroxysms require. For a child from eight to twelve years of age, 
J^ grain may be given at bed-time and repeated twice if necessary. 
For a child from two to three years of age, }{o grain may be given and 
repeated • not of tener than twice during the night. The drug should 
not be continued longer than a week or ten days. I have never seen 
unpleasant effects follow its use. 

Interrupted Medication. — It will be observed that the drugs of 
value in whooping-cough are the sedatives. It is well known that by 
the prolonged use of sedatives their effect is lost. For this reason I 
have found it wise to use what may be called ''interrupted medication." 



MEASLES 619 

Por five days the antipyrin and bromid of soda are given. Full doses 
of quinin only are then given for five additional days, at the end of 
which time the antipyrin and bromid are resumed. In this way, 
giving the drugs five days each, I continue with advantage for a month 
or six weeks. It is rarely necessary to continue the treatment longer 
than six weeks — usually from three to four weeks is sufficient. Of 
course, the child will whoop after that time, but the active stage of 
vomiting and severe paroxysms will be over. If the vomiting can be 
controlled in an attack of pertussis, and if the patient can obtain suffi- 
cient sleep, much has been accomplished. I would emphasize here, 
what has already been suggested: do not begin the drug treament of 
whooping-cough, whether by the administration of quinin, antipyrin, 
or other remedies, until the spasmodic stage is at its height. If a sedative 
is given as soon as a diagnosis is made, by the time the disease reaches 
its height tolerance will have become so established that the drug 
will have lost not a little of its sedative action. If medicines must be 
given during the earliest stage, a placebo may be used. 

Fresh air is of immense value as a means of relief in whooping- 
cough, regardless of the method of treatment followed. We are told 
that the child rarely coughs when out-of-doors, but commences as 
soon as he is brought into the house, which is usually overheated 
and badly ventilated. In nearly all cases the cough is worse at night. 
This may be explained in part by the absence of proper ventilation 
in the sleeping apartment. A child who for any reason must remain 
indoors should not be allowed to remain constantly in one room. 
There should be two rooms and every window in the one not in use 
should be freely open. The Hving-room and sleeping room should 
be kept at a fairly even temperature — from 68 to 70°F. 

MEASLES 

By some writers measles is credited with an antiquity as great as 
that of smallpox, but the fact that measles was long confused with 
other exanthemata renders it doubtful whether descriptions over two 
centuries old should be accepted. Measles has always been one of the 
most rapidly advancing of epidemic diseases. In communities long 
unaffected, such as Iceland and the Fiji Islands, it has attacked the 
greatest numbers and developed the highest virulence. In the years 
1834 to 1836, and 1842 to 1843, nearly the whole of Europe was 
invaded. 

Buxton, whose elaborate little monograph, pubhshed a century and 
a quarter ago, still affords much of value, says: ^' Those who die of 
measles generally receive their death by a great flux of serum to the 
lungs. ^' Certain it is that bronchopneumonia has always given to 
measles an importance out of all proportion to its immediate severity. 

Transmission. — Measles is the most readily transmitted of all the 
communicable diseases. A very few seconds' exposure is all that is 
necessary. Very few of the human race escape. The disease is 



620 THE PRACTICE OF PEDIATRICS 

transmitted by direct infection. Transmission through an intermedi- 
ary is not of frequent occurrence. I have never known a proved case. 

Etiology. — The disease may be transmitted from the beginning of 
the earhest catarrhal symptoms, which become manifest two or three 
days before the appearance of the rash. The most infective period is 
during the first four or five days; how much longer it may continue is 
unknown. 

Goldberger and Anderson have been able to produce measles in 
rhesus monkeys by inoculating them with the blood of human cases of 
the disease. They proved that the blood in measles is infected before 
the appearance of the rash and during effloresence of the eruption, 
while the infectivity decreases twenty-four hours after the eruption 
has appeared. The buccal and nasal secretions are also infective at 
the time of the appearance of the eruption and for forty-eight hours 
afterward. The desquamating scales, on the other hand, were not 
infective. The nature of the virus has not been proved, but it is 
filterable through a Berkefeld filter, resists drying for twenty-four 
hours, and becomes inert after fifteen minutes' exposure to 55°C. 

Lucas and Prizner have confirmed the work of Anderson and Gold- 
berger, and showed further that the inoculated monkeys develop 
Koplik spots just as do human subjects. 

Age. — No age is exempt. In scarlet fever and diphtheria, nature 
surrounds the very young with a certain degree of immunity. The 
tenderest age is susceptible to measles, although it rarely occurs in 
infants under six months of age. 

Incubation. — The period of incubation ranges from seven to four- 
teen days. It is rare for the disease to develop after the tenth 
day following exposure. I have known a very few cases to develop, 
however, as late as the fourteenth day. 

Symptoms. — In marked contrast to scarlet fever, measles is fairly 
constant in its manifestations. Very severe cases and very mild cases 
are encountered. Institutional children have measles much more 
severely than do private patients, and the former cases are much the 
more fertile in complications. This is because of the natural dis- 
advantages which an institution necessitates, no matter how well 
it is conducted. The complications are more frequent because of 
the more frequent presence of secondary infection to produce the 
complications. 

The Eyes. — The first manifestation of the illness is a coryza with 
mild conjunctivitis. The eyelids become swollen and reddened at the 
margins. There is photophobia. 

Cough. — A cough is present from the beginning or develops in a 
short time. The cough is hard, teasing, and, early in the attack, 
without bronchial secretion. Occasionally the cough will be hoarse 
and croupy, but this is of rare occurrence. 

Nervous Manifestations. — Convulsions occur very rarely, and when 
present are usually due to indigestion. The child is very restless 
and unhappy until the eruption is well developed. 



PLATE II 





FlQ. 1, 



Fra. 2 





Fig. 3. 



Fig. 4. 



The Pathognomonic Sign of Measles (Koplik's Spots). 

Fig. 1.— The discrete measles spots on the buccal mucous membrane, showing the 
isolated rose-red spot, with the minute bluish-white center, on the normally colored 
mucous membrane. 

Fig. 2. — Shows the increased eruption of spots on the mucous membrane of the 
cheeks; patches of pale pink interspersed among rose-red areas, the latter showing 
numerous pale bluish-white spots. 

Fig. 3. — The appearance of the buccal mucous membrane when the measles spots 
coalesce and give a diffuse redness, with myriads of bluish-white specks. The ex- 
anthema is at this time fully developed. 

Fig. 4. — Aphthous stomatitis sometimes mistaken for measles spots. Mucous 
membrane normal in color. Minute yellow points are surrounded b}^ a red area. 
Alwavs discrete. 

(The Medical News, June 3, 1899) 



MEASLES 621 

The Rash. — The characteristic rash usually makes its appearance 
about the ears and over the neck and upper portion of the chest. 
From here it spreads to the entire body, the last portions involved 
being the feet and hands. In its disappearance, the rash follows the 
same order. It consists of red papules and macules of irregular 
shape and of variable size. Early in all cases, and throughout most mild 
cases, there are areas of uninvolved skin between the erupted areas. 
In severe cases the areas of eruption coalesce so that the face, trunk, 
and Hmbs or the entire skin surface may present a livid, deeply con- 
gested appearance. The face, covered with the diffuse rash, swollen 
and edematous, the eyes with the swollen lids closed and secreting, and 
the thin, watery nasal discharge present a picture seen in many cases 
of measles and never elsewhere. 

The rash is sometimes quite irregular in the time of its appearance 
after the onset of symptoms. I have seen it occur very early, coin- 
cident with the onset of the catarrhal symptoms, and I have seen it 
delayed for a week. The eruption requires from three to six days to 
complete development. 

Temperature. — Pronounced fever does not develop until the appear- 
ance of the rash. Both the temperature and the rash reach their great- 
est intensity at the same time. Rarely there is a prodromal fever for 
a few hours. This may reach 103° to 104° F. This fever subsides 
quickly and the indications are that the exposed child will not develop 
the disease. Within forty-eight hours, however, or less, the tem- 
perature again begins to rise with the appearance of the rash. In 
cases of this nature I have had difficulty at the outset in persuading 
parents of the necessity of keeping the child in his bed, or even in the 
house, as the illness is looked upon by the family as a cause of false 
alarm. 

Diagnosis and Differential Diagnosis. — The diagnosis in most cases 
of measles is not difficult. A mild case may closely simulate one of se- 
vere German measles. The presence of Koplik spots (see Plate II) on 
the buccal mucous membrane, the conjunctivitis, and cough are usually 
sufficient to mark the case as one of true measles. 

There are no other skin manifestations of disease that simulate 
those of measles sufficiently to occasion confusion. 

Complications. — Children with measles almost always have some 
bronchitis. In fact, a mild degree of bronchitis occurs so regularly 
that it may be looked upon as part of the disease. 

Bronchopneumonia is the most frequent complication, because the 
diseased mucous membrane of the respiratory tract becomes a fertile 
field for infection with pneumococcus and other pathogenic bac- 
teria. The mortality in institutions for children with measles is al- 
ways large, because of the complication of bronchopneumonia. In a 
recent epidemic of measles thus complicated, in a New York institution 
for children, there was a mortality of 40 per cent. 

Otitis, — Acute, simple, and suppurative otitis is a fairly frequent 
complication. Its presence should be suspected when the temperature 



622 THE PRACTICE OF PEDIATRICS 

is continued and does not subside with the disappearance of the rash. 
The absence of pain does not mean that the ears are normal. In the 
majority of my cases of suppurative otitis in young children pain has^ 
been absent. 

Nephritis is a very rare complication. I have seen but one case. 

Adenitis. — Adenitis is a rare complication. 

Recurrence or Second Attack. — I have known of one recurrence 
after a two-year interval in a girl seventeen years of age. I attended 
her during both attacks, the last of which was very severe, and followed 
by a moderately severe nephritis. The family, most intelligent and reli- 
able people, insisted that the girl had had measles at an earlier age, to- 
gether with other members of the household. If such was the case, 
she had three attacks of measles. 

A brother of the patient was also reported by the mother to have 
had two attacks of the disease. 

Prognosis. — The prognosis is good in the cases in which pneumonia 
does not enter. I have never known a fatal uncomplicated case of 
measles. 

Treatment. — General Management. — The popular conception of the 
management of measles is that the patient should be warmly wrapped^ 
given hot drinks, and kept in a warm room with little or no ventilation. 
An attack of measles renders the child temporarily a very susceptible 
subject for bronchopneumonia. The younger and more delicate the 
child, the greater the danger. The darkened room, with its closed 
windows and dust, the extra wrappings, with the resulting failure of 
heat radiation, the reduced vitality, and the resulting loss of appetite 
do much to prepare the way for an infection of the respiratory tract, 
which so often occasions pneumonia and bronchopneumonia. If to a 
case of this nature whooping-cough be added, we have, with few ex- 
ceptions, a hopeless condition. 

A child ill with measles should be comfortably clad in the usual 
night-clothes and kept in bed. No extra wraps are required, nor is it 
desirable to keep the room at a higher temperature than is customary 
— 68° to 70°F. is a suitable room temperature. There are many grada- 
tions of light between glaring sunlight and utter darkness. Both are 
extreme and one almost as undesirable as the other. It is my custom 
to advise that a window-shade of dark green be lowered within one 
foot of the window-sill. The light brown or drab shade should be 
lowered completely. If the shade is white, or of a very light color, and 
not supplemented by a curtain of dark material, it will be necessary to 
exclude the bright light by some other means. If the child is old enough 
I allow him to dictate the degree of light. Any intelligent child will 
know when the light is painful to him. 

Feeding. — The patient should be put on a greatly reduced diet. For 
the bottle-fed, the milk mixture should be diluted at least one-half by 
adding boiled water, and the same quantity given as in health. The 
appetite in the early stage of measles is practically absent, so that little 
or no food is taken. Patients may be given water to drink freely at 2^ 



MEASLES 623 

temperature not lower than 50°F. For "runabout" children, eighteen 
months of age and over, the diet as suggested for the sick (see p. 109) 
should be given. 

Bowel Function, — There should be one evacuation of the bowels 
daily. An enema should be given when this does not otherwise take 
place. The urine should be examined every second day. 

The Eyes. — During the waking hours the eyes should be generously 
bathed every hour or two with a 3 per cent, solution of boric acid applied 
with old linen or cotton, which is afterward destroyed. 

The Ears. — Otoscopic examination should be made every second 
day until the case is discharged. In the event of a sudden rise in 
temperature during convalescence, which cannot be explained by the 
condition of the intestine, lungs, or throat, such an examination should 
be made by an expert. 

Baths. — The temperature of uncomphcated measles is rarely high 
enough to call for special measures. If it should have a tendency to 
continue about 104°F. for eight or ten hours and the child be uncom- 
fortable and restless, a tepid sponge-bath of ten or twenty minutes 
duration may be given, and repeated at intervals of two ot three hours. 
Whether the fever demands bathing or not, the patient should be 
sponged twice a day with tepid water at 100°F. After he has been 
dried an application of cold-cream, liquid albolene, or olive oil should 
be made to the entire body. This is to be given for the sole reason that 
it relieves the itching, induces sleep, reduces the temperature, and 
thus enables the child to pass through the disease with less discomfort. 

Delayed Rash. — Now and then a case is encountered in which the 
rash is slow in appearing. The temperature is high — 104° to 105°F., 
— the skin hot and dry, and the child very uncomfortable, perhaps de- 
Hrious. For such patients a hot bath — 105°F. to 110°F. — of from 
three to five minutes' duration, often brings out the rash and greatly 
relieves the symptoms, which may have been of an urgent character. 
In removing these children from the bath care must be exercised to 
keep them wrapped for fifteen to twenty minutes in a blanket which 
has previously been warmed. 

The Cough. — The cough of measles during the active period of the 
attack is one of the annoying features of the disease, and one for which 
some rehef must be attemped, particularly if the child is kept awake 
at night. The ordinary expectorants alone are of no service in treat- 
ing the cough of measles. Only a sedative will give rehef. To a child 
six months of age from 5 to 8 drops of paregoric may be given, and re- 
peated if necessary after an interval of two hours. The following com- 
bination of paregoric and sweet spirits of niter is often of service : 

I^ Tincturae opii camphoratse gtt. x 

Spiritus aetheris nitrosi gtt. iij 

M. Sig. — One dose; to be repeated every two or three hours (for a child 
of eighteen months or older). 

From the first to the second year, 10 to 15 drops of paregoric or 3^^ 
grain of Dover 's powder may be given at two-hour intervals, if required. 



624 THE PRACTICE OF PEDIATRICS 

Usually but two or three doses of the sedative will be necessary during 
the night. Should the paregoric or Dover's powder be objectionable 
because one may dislike to give opium to young children, from 3 to 4 
grains of sodium bromid in 2 drams of water, repeated as required every 
hour or two, will be of service for a child under two years of age. From 
the second to the fifth year 1 grain of Dover 's powder, or from 15 to 25 
drops of paregoric, or }{o to }i grain of codein, may be given at 
intervals of from two to four hours. 

If bronchitis develops sufficiently to require treatment, as it does 
in at least one-half the cases, the means for the management of bron- 
chitis suggested on p. 311 will be found useful. The temperature of a 
child ill with measles should be taken three times daily, and the lungs 
and heart should be examined every day. 

Vapor. — It is my custom to keep the air of the sick-room moistened 
with vapor during the entire illness. Its benefits are twofold: It 
reheves the cough, as it is more agreeable than dry air to the congested 
mucous surface during the early stage; and it prevents the free circula- 
tion of dust, the danger of which has already been referred to. If the 
room is carpeted, it should be well sprinkled with water before sweep- 
ing. If, fortunately, the floor is bare, the broom can be dispensed with 
and a damp cloth used instead. 

Fresh Air. — Not only should the air of the sick-room be vapor- 
charged, but it should be frequently changed through proper ventilation. 

Quarantine. — The length of quarantine is usually from twelve to six- 
teen days, at least ten days of which time are spent in bed. 

GERMAN MEASLES (ROTHELN; RUBELLA) 

German measles is a disease of the runabout and school-child. It 
rarely occurs in infants. It is one of the mildest diseases of the trans- 
missible class. 

Etiology. — The specific etiologic agent of German measles is quite 
unknown, but that it is not identical with that of either measles or 
scarlet fever is evidenced by the fact that an attack of rubella does not 
protect against either of these diseases. 

Transmission is by direct contact. I have never had proof of the 
transfer through an intermediary. I have never known of a second 
attack. 

Incubation. — The period of incubation is from two to three weeks. 

Symptoms. — The first symptom is usually the rash. The tem- 
perature rarely goes above 101°r. In a very few cases I have known 
the temperature to rise to 102°F., and the rise has occurred at the on- 
set of the illness. The catarrhal symptoms are negligible. There is 
rarely more than a sHght injection of the conjunctiva. 

The rash is not only the first manifestation of the disease, but it 
remains the principal evidence of the infection. The eruption closely 
resembles that of measles, and differentiation between the two diseases 
from the standpoint of the rash may be difficult. It usually appears 
first about the ears and neck and spreads rapidly. The eruption at 



DIPHTHERIA 625 

first is distinctly smaller than that of measles; it is papular and varies 
from a faint red to a deep red color; rarely it is distinctly punctate. 
When this is the case, the erupted areas may coalesce, producing a 
diffuse blush not unlike that of scarlet fever. The eruption is usually 
very temporary, lasting from one to three days. It disappears after 
the order of its appearance, leaving the face and the neck first. There 
is no resulting pigmentation or discoloration of the skin, such as may 
occur in true measles. 

There is no involvement of the buccal surfaces. 

Lymphatic Gland Enlargement. — Enlargement of the glands at the 
angle of the jaw and the post-cervical glands, particularly the latter, 
occurs so consistently that this condition may be put down as one of 
the prominent symptoms of the disease. The glandular involvement, 
however, is very slight, and disappears in from two to four days. The 
glands in the axilla and groin very rarely show involvement. 

Desquamation. — Only the severer cases are followed by a slightlj^ 
branny desquamation. 

Diagnosis and Differential Diagnosis. — The disease may be confused 
with measles, scarlet fever, and the indigestion and drug erythemata. 
The mildness of the symptoms is a strong point in favor of German 
measles. Exceptionally, a severe case may be difficult to differentiate 
from true measles. In such an instance the absence of eruption on the 
buccal mucous membrane (Koplik spots) is a valuable aid. Further, 
the lymph-gland enlargement does not occur in measles. 

Scarlet Fever. — The characteristic angina, which is a fairly constant 
symptom in scarlet fever, is never present in measles. There is no post- 
cervical gland enlargement early in scarlet fever; and while the rash 
of German measles may resemble that of scarlet fever, the former 
exanthem is coarser in appearance, the punctate dots are larger, and the 
rash presents a blotched appearance, in contradistinction to the general 
diffuse intense blush of scarlet fever. In scarlet fever, furthermore, the 
desquamation is characteristic. In erythema due to drugs there is no 
manifestation of illness of any nature. A rash due to indigestion is 
very transient and is apt to be urticarial in type. 

Complications. — I have never known a comphcation to develop 
with this disease. 

Prognosis. — I have never known a fatal case. 

Treatment. — Rest in bed for about two days, confinement to the 
house for a slightly longer period, reduced diet, and the promotion of 
free bowel action are usually all that are needed. Recovery is ordi- 
narily complete in six to eight days from the beginning of the attack. 

Isolation is not a necessity unless there are very young or delicate 
children in the family. 

DIPHTHERIA 

Diphtheria has been known by its present name for less than a 
century, although the terms ''ulcus Syracum" and ''ulcus Egyptacum," 
together with references to certain anginas with very pecuKar expec- 
40 



626 THE PRACTICE OF PEDIATRICS 

toraiion, indicate that the disease was prevalent as far back as the time 
of Hippocrates. As early as 100 B. C. Asclepiades, of Bithynia, quoted 
by Galen and Aretseus, is said to have known diphtheria and practised 
laryngotomy. Aretseus gave the first important description of 
^'angina gangrenosa," and Galen, in the second century, described the 
membranous expectoration. 

Not, however, until the early part of the eighteenth century did 
study of the disease become productive. In 1719 Wolfgang Wedel, of 
Jena, issued a document on the value of isolation. A little later an 
epidemic near Boston, and in 1745 another in Paris, resulted in the 
description of cutaneous diphtheria and of paralysis of the palate and 
eye muscles. Home accurately described the membranes in 1765 and 
invented the term ''croup," to differentiate the condition under dis- 
cussion from the ''angina maligna" or "gangrenosa" of ancient writers. 
Not until the publication in 1826 of Bretonneau's famous treatise on 
the epidemics at Tours was the pathology of the disease accurately 
defined. Bretonneau combined all the inflammations previously .called 
angina gangrenosa, ulcers, and croup under the term, diphtheria 
(At</)0i7pa, a membrane) and asserted his belief that direct inoculation 
and contact were the only modes of transmission. 

The later history of diphtheria contains its two most important 
epochs: the discovery by Klebs of the bacillus, in 1883, with its isolation 
and cultivation by Loffler in 1884; and the introduction of antitoxin 
into general use as a result of long experimentation (by Behring, Roux, 
Martin, Chaillon, and Yersin) with the serum of actively immunized 
animals. Since the report of Roux in 1894 that m certain hospitals 
antitoxin had reduced the mortality from 58 per cent, to 20 per cent., 
the wider and more intelligent use of this specific has revolutionized the 
disease. 

Age of Patients. — Diphtheria is of rare occurrence before the first 
year, although no age is exempt. My youngest patient was five 
months of age. A case in the practice of a colleague occurred at the 
sixth week. The most susceptible age is between the second and the 
tenth year. 

Predisposition. — Vigor of constitution appears to exert no influence 
on susceptibility to the disease. The strong and the delicate are alike 
subject to the infection. 

Diseased Throats. — The presence of diseased tonsils and adenoids 
appears to be a decided predisposing factor. Throats so involved 
possess a poor resistance to the infection. It is my observation that a 
normal throat is the best prophylactic agent, which means that chil- 
dren whose diseased tonsils and adenoids have been removed have the 
best chance to escape after an exposure. 

Transmission. — Diphtheria is contagious and infectious ; transmis- 
sible through contact— contagious; and through an intermediary — in- 
fectious. Transmission from the diseased to the well is usually through 
personal association. That the disease may be transmitted through an 
intermediary person, book, or article of clothing, is not to be questioned. 



DIPHTHERIA 



627 



Nevertheless, I am confident that sources of exposure are much less 
frequent than is generally accepted. The sources of many obscure in- 
fections are the mild ambulatory cases. Diphtheria may be so mild in 
an individual that its presence is not suspected, and to such cases is due 
in many instances the spread of the disease. 

Diphtheria Carriers. — In several instances I have demonstrated the 
presence of the diphtheria bacillus in the nasal secretions of healthy 
children. In a series of observations in pubUc school children in Balti- 
more Styles found diphtheria bacillus in 5 per cent, of cases. 

Bacteriology. — The morphology of the Klebs-Loffier bacillus varies 
greatly, but it has a characteristic irregularity of staining and 
regularity of grouping which are aids to diagnosis. Its demonstration 
in smears or cultures from the site of the lesion is a necessity for the 
diagnosis of diphtheria. With the weakly alkaline methylene-blue 
stain recommended by Loffler the bacilli appear striped, unevenly 
beaded, granular, or clubbed ; they are arranged in groups of four or six 
elements, lying parallel or at sharp angles. 

The most frequent localization of Bacillus diphtherise in the human 
body is on the mucosa of the throat, larynx, and nose. It may travel 
down into the lung, causing bronchopneumonia, or into the stomach, 
causing pseudomembranous gastritis. The bacilli have been found in 
pus from the middle ear, and the pseudomembranous lesions on the 
skin and vulva. As a rule. Bacillus diphtherise remains localized at 
the site of the lesion it has produced, and only in very rare instances 
does it invade the blood — probably as a terminal condition. The 
toxin formed by the bacillus is responsible for the general symptoms. 

The bacillus may persist in the throat for weeks after an attack of 
diphtheria, however mild such an attack may have been. These bacil- 
lus carriers become a menace to other persons, since a mild attack of 
diphtheria in one individual may yet produce a severe case in another 
person. 

The Schick Test. — In the Schick test a minute quantity of diph- 
theria toxin is introduced intra-dermally. The effects indicated by a 
local reaction determine the susceptibility of the individual to 
diphtheria. 

Susceptibility to Diphtheria. — As mentioned elsewhere very young 
infants have been looked upon as possessing a natural immunity to 
diphtheria. Among several hundred cases I have seen but two under 
six months of age. 

Interesting observations as to the susceptibility of children at 
various ages have been published by Schick, as follows : 



Age 



Total 



Schick's 



Positive 
Schick's 



Per cent, 
positive 



New-born . . . 

1st year 

2 to 5 years. . 
5 to 15 years 
Totals 



291 

42 
150 
264 

747 



275 
24 
55 

133 

487 



16 

18 

95 

131 

260 



7 

43 

63 

50 

34-9 



628 THE PRACTICE OF PEDIATRICS 

It will be observed that in the newly born but 7 per cent, were 
susceptible to diphtheria. Among 747 children under fifteen years 
but 34.9 per cent, were susceptible to the disease. It has also been 
proven that an attack of diphtheria not only causes no immunity but 
renders the individual more readily susceptible to future attacks. 

It has also been demonstrated that susceptibility runs in families. 
When one child in a family is positive others are apt to be positive, and 
the same holds with negative reactions. 

Technic. — Schick published an elaborate technic which was not 
practicable for ordinary purposes. Park and Zingher have simplified 
the technic and I am indebted to them for the instructions as to its 
application. 

The toxin is supplied in capillary tubes. The contents of a tube is 
mixed with 10 c.c. of sterile salt solution and 0.2 c.c. of the solution is 
injected intradermally with a fine hypodermic needle. 

There may be three results following intra-cutaneous injection of 
diphtheria toxin : 

Negative. — Where no local reaction at all occurs about the injec- 
tion point. 

Pseudo-positive (Plate IV) (meaning not positive at all). — Where a 
red area, probably anaphylactic in character, appears within the first 
twelve to twenty-four hours, but disappears in thirty-six to seventy- 
two, with little or no pigmentation. 

Positive (Plate III). — Where in thirty-six to forty-eight hours, a red, 
generally clearly outlined area about one-half to 2 cm. appears about 
the injection point, which lasts, becoming a brick red in two, three or 
four days, the skin then wrinkling and scaling, after which the dis- 
coloration gradually disappears taking three to six weeks to entirely 
disappear. 

Negative signifies immunity. There is sufficient antitoxin in the 
system to neutralize the poison introduced. 

Pseudo-positive also signifies immunity. 

Positive signifies no immunity. There is not enough antitoxin in the 
system to neutralize the poison introduced. The individual reacting 
positive is susceptible to diphtheria. 

The Schick test is particularly useful in institutions where it is desir- 
able to know the susceptibility of the patients relative to the use of 
immunizing doses of antitoxin. The possibilities of the pseudo-posi- 
tive reaction which might necessitate a delay in the true reading of the 
reaction have induced investigators to eliminate it if possible. Koplik 
and Unger* have devised a simple method which they claim eliminates 
the pseudo-positive reaction in 75 per cent, of the cases. Their technic 
is as follows: "After an area of skin on the forearm has been cleansed 
with alcohol, the latter is encircled with the thumb and index-finger, 
and the skin held tense between them. The needle is dipped into the 
bottle of pure undiluted diphtheria toxin and then immediately inserted 
intradermally. It is important that the needle be inserted intrader- 
* Journal A. M. A., vol. Ixvi, No. xvi. 



PLATE 111 




Shows four typical positive Schick reactions of varying degrees of intensity 
forty-eight hours after test; (a) is a strongly positive reaction, with vesiculation 
of the surface layers of the epithelium, which is seen occasionally in individuals 
who have practically no antitoxin; {b) and (c) are positive reactions; (d) a mod- 
erately positive reaction. 



Shows a fading positive Schick reaction one to four weeks after test in various 
stages of scaling and pigmentation; (a) shows redness, scaling and beginning 
pigmentation after one week; (b) and (c) pigmentation after two and three 
weeks; (d) faint pigmentation after four weeks. 

(ZiNGHER, American Journal of Diseases of Children, April, 1916.) 



PLATE IV 




Shows two pseudoreactions forty-eight hours after test, and a combined 
reaction; (a) mild; (b) marked; (c) a combined positive and pseudoreaction. 

(ZiNGHER, American Journal of Diseases of Children, April, 1916.) 



DIPHTHERIA 629 

mally and not subcutaneously. The needle is an ordinary hypodermic 
bent at a distance of one-quarter inch from its point so as to make an 
angle of about 170 degrees. The angle aids in inserting the needle in- 
tradermally. From the place of bending to the distal end it is 
shielded so that only the unshielded one-quarter inch can be inserted into 
the skin. The needle is so constructed that when it is inserted its full 
length the amount of toxin carried in is approximately one-fiftieth of 
the minimal lethal dose. We have had the needle weighed before and 
after dipping it into the toxin and the difference was found to be 
0.0001 gm., which was the ultimate possibility of weighing of the scales 
used. 

There can be nothing simpler than this technic. It is practically 
painless. It obviates diluting the toxin, thereby eliminating the 
paraphernalia needed for this purpose. The pure toxin kept on ice 
retains its potency for one year. The diluted toxin used in the Schick 
technic deteriorates in twenty-four hours. Another very important 
advantage is the reduction of pseudo-reactions to a minimum. 

The authors believe that the pseudo-positive reaction is due to 
trauma, due to injecting intradermally 2 c.c. of the diluted toxin, and 
that it is not the result of anaphylaxis. 

Zingher* states that three prerequisites are necessary for the test: 
(a) a reliable toxin, (b) a proper technic, and (c) a correct interpretation 
of the reaction. Care in getting and keeping the toxin will answer the 
first. A good syringe (preferably a 1 c.c), and a fine, sharp but short- 
beveled platinum-iridium needle are needed for the second. The ability 
to carry out the test properly is easily acquired. One point that 
may serve in guiding one in the injection of the diluted toxin might be 
emphasized. If the needle has been inserted in the proper layer of the 
epidermis, then the oval opening of the needle will be visible through 
the superficial layers of cells. A definite wheal-like elevation, with the 
distinct markings of the openings of sweat-glands, shows that the in- 
jection has been made properly, and that the fluid is confined to a small 
area of the epidermis. Here it will exert its irritant action if the 
individual tested is not immune to diphtheria. 

Conclusions. — 1. The great practical value connected with the 
Schick test makes it desirable that the results obtained with it should 
be reliable. 

2. The accuracy of the results will depend not only on the toxin, 
but also on the care with which the test is made, and on the interpreta- 
tion of the reaction. 

3. The undiluted toxin is available in bulk or in capillary tubes. It 
should be well ripened and always kept cold and in a dark place. 

4. The positive reaction should be considered as indicating a lack of 
immunity, unless the pseudoreaction can be eliminated by a control 
test. The negative reaction is a definite sign of immunity. 

5. It is important to remember that, in using diphtheria toxin in the 
Schick test, we are deahng with an accurate quantitative reaction, and 

*Amer. Journal Diseases of Children. 



630 THE PRACTICE OF PEDIATRICS 

handling carefully measured amounts of an active agent, that has a 
tendency to deteriorate, even in bulk, if it is not properly protected 
from light and exposure, and kept in a very cold place. 

6. The results with the test obtained in 2700 normal children, show 
that from 17 to 32 per cent, between the ages of 2 and 16 years give a 
positive reaction and are probably susceptible to diphtheria. 

Pathology. — Following an invasion of the mucous membrane by the 
specific bacillus, a pseudomembrane is thrown out which is firmly ad- 
herent to the underlying mucous membrane. The false membrane 
may be thin and grayish in color, or thick and yellow. 

It is the result of exudation into the mucosa, ulceration, and ne- 
crosis. The mass thus formed is composed chiefly of fibrin, in the 
meshes of which are entangled polynuclear leukocytes, desquamated 
epithelium, and bacteria. The fibrin may be deposited in fairly 
definite layers. Ulceration and small hemorrhages occur in the sub- 
jacent tissue, which is very edematous, and detachment of the mem- 
brane may leave a raw, bleeding surface. When the separation occurs 
naturally, the loosening process is one of autolysis, and large defects 
in the tissue are healed by granulation. New epithelium is generally 
flat, and cicatricial contractures are common. The Klebs-Loffler bacilli 
present in the exudate during the acute stage are usually associated 
with other organisms, such as streptococci and staphylococci, which 
determine to some degree the appearance of the membrane. 

Any of the mucous surfaces may be involved. Under my own obser- 
vation the process has involved the nasal cavities, the lips, the mouth, 
the conjunctiva, tonsils, pharynx, trachea, and bronchi, and in one 
case the esophagus. The involvement of the trachea, bronchi, and 
esophagus was proved at autopsy. The rectum and vagina have been 
the seat of the disease. 

Incubation. — The period of incubation is variable. It may be but 
a day or two, or it may be several weeks. According to estimate, 1 per 
cent, of school-children carry the bacilli in their throats in a viable form, 
and yet by no means 1 per cent, of the children develop the disease. 

Symptoms. — One of the most important features of diphtheria, in 
the great majority of cases, is the slow and gradual onset. At first the 
child may complain of being tired or sleepy and of loss of appetite. 
Symptoms referable to the throat may appear, but pain is not neces- 
sarily present. The breath becomes offensive. The physician is sent 
for on the first, second, third, or some later day, depending upon the 
intelligence of the parents or nurse or upon their confidence in them- 
selves to care for what, at the time, appears to be a simple condition. 
The child, not willing to go to bed, is looked upon by the uneducated 
eye as being not at all sick. By the time the case is seen by a physician 
much valuable time may have been lost. The earlier antitoxin is used, 
the more certain the recovery. A delay of forty-eight or even twenty- 
four hours may mean a fatal issue. Not every case has so gradual an 
onset. 



DIPHTHERIA 631 

Illustrative Cases. — In the pre-antitoxin period, late in the eighties, an asylum 
patient died eighteen hours after the appearance of the first symptom. 

In March, 1910, a father came to my office leading by the hand two children, 
aged three and six years. Both had been ill about three days with fever and some 
difficulty in swallowing. They were supposed to have tonsillitis. The children 
had not seemed at all ill to the father. A glance showed that they were ill. On 
further examination both throats were found filled with membrane. They were 
at'once sent to the Willard Parker Hospital and given large doses of antitoxin. One 
child died in twelve hours and the other in twenty-eight hours. 

Localization of the Membrane. — The usual site of the membrane is 
on the tonsils and the pillars. The pharynx is more rarely involved, 
and when involved, has usually become affected through extension of 
the primary lesion. 

Temperature. — The temperature, unfortunately, is rarely high early 
in the case. It seldom rises above 102°F. The lower temperature and 
gradual onset are accountable for many deaths, the physician being 
called late in the disease. 

The Lymph Glands. — Swelling of the lymphatic glands at the angle 
of the jaw is an early symptom in about 30 per cent, of the cases. 

Diagnosis. — Visible membrane should always be looked upon as 
diphtheric, and treated accordingly with antitoxin. I have looked into 
thousands of throats, and feel sure that the man is yet to be born who 
can say, after inspection alone, that a given membrane is not due to the 
Klebs-Loffler bacillus. There is no invariable manifestation, no reliable 
characterization, of pseudomembrane due to the Klebs-Loffler bacillus. 

Antitoxin should be given in any suspected case, and then a culture 
should be taken. Following out this practice, I have given antitoxin 
to children who did not have diphtheria, as proved by repeated cultures. 
Never have I regretted this practice. 

Differential Diagnosis. — Both the streptococcus and staphylococcus 
will produce a membrane identical with those produced by the Klebs- 
Loffler bacillus, and the disease may be differentiated only through cul- 
tural examination. 

Tonsillitis. — In tonsillitis the temperature is high — 103° to 105°F. 
The child is usually much prostrated, and appears very ill. The 
physician accordingly is called much earlier to the patient ill with ton- 
sillitis than to the one ill with diphtheria. 

In tonsillitis the tonsils are more apt to be swollen and enlarged, the 
exudation appearing in the form of white dots which stud the surface. 
Care must be exercised, however, in cases which appear to be those of 
frank tonsillitis. The points of exudation may coalesce and in a day or 
two may produce a distinct membrane firmly organized. It is my cus- 
tom to make a culture in every case showing visible exudation, whether 
this is on the tonsils or elsewhere. 

Illustrative Case. — A mother developed fever and sore throat. The left tonsil 
was clear. On the right tonsil there were three or four yellowish-white points of 
exudation. The condition was pronounced tonsillitis by the physician in attend- 
ance, and she was not visited further. In four days the doctor was again sent for, 
and found she had diphtheria with extensive membrane on both tonsils. The 
mother passed through a desperate illness and recovered completely in six months. 
In addition to a myocarditis she developed diphtheric paralysis of both lower ex- 
tremities. Two of her three boys who were my own patients developed the 



632 THE PRACTICE OF PEDIATRICS 

disease and recovered without inconvenience because of the early and free use of 
antitoxin. 

I could recite many other instances of the atypical onset of diph- 
theria. I have learned never to look lightly upon a throat showing 
exudation on its mucous membrane. 

Prognosis. — A favorable prognosis in a given case depends largely 
upon two factors: An early diagnosis and a knowledge of the use of 
antitoxin. The natural resistance of the patient is an important fea- 
ture, and particularly important is the condition of the throat, whether 
normal and resistant, or filled with diseased tissue, supplying a favor- 
able culture field for the invading bacilli. 

Complications. — The complications, in their order of frequency, are 
bronchopneumonia, nephritis, endocarditis, otitis, adenitis, and diph- 
theric paralysis. 

Treatment. — Owing to our knowledge of the etiology of diphtheria, 
and as a result of the advent of the specific remedy, antitoxin, the dis- 
ease has lost much of its former terror. Diphtheria is still, however, 
an important contributor to the death-rate of all large cities. This is 
due, first, to parents who fail to appreciate the possible dangers that 
may arise from a sore throat and who neglect to call a physician early 
in the illness, and, secondly, to physicians who do not believe in diph- 
theria antitoxin, who timidly use it in small doses late in the disease, or 
who wait for positive clinical signs or a report of a culture before using 
the remedy. Equally as necessary as the realization of the value of 
antitoxin is the knowledge of how and when to use it and when to re- 
peat its use. In many cases, at the beginning of the disease, when the 
tonsils alone are involved, it is impossible, without the aid of the labora- 
tory, to differentiate diphtheria from tonsillitis. I have seen case after 
case in the pre-antitoxin period, in which two or three days were re- 
quired to make a positive chnical diagnosis. In towns in which a 
bacteriologic examination is possible it is in some instances safe to wait 
for a report from such an examination. When one is in doubt, a safer 
rule to follow in those cases in which there is pseudomembrane on the 
tonsils is to give antitoxin at once. If the case proves to be one of 
simple tonsillitis, no harm will follow. I have repeatedly given full 
doses of antitoxin to patients in whom we afterward learned there was 
no diptheria, without any unfavorable results. 

Illustrative Case, — During the winter of 1906-07, I was called to see a little girl 
six years old with a gray, membranous patch on the left tonsil, of the size of the 
thumb-nail. There was a temperature of 101°F. The child complained of feeling 
tired, seemed generally wretched, and had considerable difficulty in swallowing. I 
immediately gave 3000 units of antitoxin and sent to a private laboratory a culture 
from the throat. Next morning the report reached me that the Klebs-LofHer 
bacillus was absent. On visiting the patient at this time I found that the mem- 
brane had extended and now covered the right tonsil. I repeated the antitoxin, 
giving 3000 units, and took another culture. This was sent to another private 
laboratory. Again the report was negative for the Klebs-Loffler bacillus, but the 
culture showed a pure growth of the streptococcus. The following morning the 
throat began to clear, and in two days was normal. Clinically this case was one of 
diphtheria. There was no scarlatina, but there was some swelling of the glands at 
the angle of the jaw. Aside from the improvement, the child showed no symptoms 
whatever to indicate that antitoxin had been given. 



DIPHTHERIA 633 

Necessity for Promptness in the Use of Antitoxin. — When there is 
diphtheria and we wait for positive chnical signs or for the report of a 
culture, if only for ten or twelve hours, we lose most valuable time. 
Such a delay may be responsible for a fatal termination. If there is one 
thing, in addition to its great usefulness, that we have learned by the 
administration of antitoxin, it is the necessity of giving the agent at the 
earhest possible moment in the disease and of giving it in full doses. 
When in doubt, give antitoxin. The age of the child determines in no 
way the amount to be given at one time. 

Dosage. — Five thousand units should be given at the first injection. 
When there is membrane on the uvula, the pillars of the fauces, the 
posterior pharyngeal wall, or in the nose, we should never await the 
report of a culture, but give a full dose of antitoxin at once. This 
should be repeated eight to twelve hours later if there is an extension 
of the membrane or if there is no change in its appearance. If the 
throat shows a tendency toward improvement, if there is a curling up 
and loosening of the edges of the membrane, or if it has taken on the 
granular appearance peculiar to diphtheric membrane after the use of 




Fig. 85. — "Record" antitoxin syringe. 

antitoxin, we may safely wait twelve hours longer — twenty-four hours 
in all — before deciding whether a repetition of the original dose or the 
administration of a smaller one is required. In the nasal cases, a di- 
minution in discharge, a lessening of the breath fetor, a reduction in the 
glandular swelling, and a fall in the temperature — all are indications 
of improvement, but the physician should not rest unless the constitu- 
tional improvement and the clearing-up process are rapid and complete. 
When the case shows no sign of improvement, more antitoxin should 
be given. 

A child ill with diphtheria must be looked upon as poisoned. Anti- 
toxin is the antidote, and every case must receive enough of the antidote 
to neutralize the poison. Whether enough antidote will be supplied 
depends upon the duration of the infection when seen by the physician, 
and upon his ability to apply the remedy. If the case is seen on the 
third day or after 10,000 units should be the initial dose and may be 
repeated as suggested above. 

Means of Injection. — There are several antitoxin sjrringes on the 
market, any one of which may be used if it will admit of repeated boil- 
ing, for in every instance the syringe should be boiled before using. 
The ''Record"* antitoxin syringe ( Fig. 85) satisfactorily fulfils these 
requirements. Some of the private producers of antitoxin furnish it 

* The "Record" antitoxin syringe may be obtained from James C. Dougherty, 
409 West Fifty-ninth Street, New York. 



634 THE PRACTICE OF PEDIATRICS 

in a glass bulb with an appliance for subcutaneous injection. The 
advantages possessed by this combination are its convenience and its 
safety, for as the instrument has to be used but once, the danger of 
infection by means of a syringe which is used repeatedly is thus avoided. 

Site of Injection. — The skin over the abdomen between the umbilicus 
and the anterior spine of the ilium is doubtless the most convenient 
site for the injection. The skin is very loosely attached at this point 
and the serum passes freely under it, requiring very little force and 
producing no laceration of the tissues or soreness of the parts suf- 
ficient to interfere with the child's customary position in bed. If the 
buttocks, favorite sites for the injection, are selected, the needle should 
be inserted well upon one side, so as not to interfere with the resting 
posture of the child. 

Before injecting, the skin should be thoroughly scrubbed with green 
soap and washed with alcohol. Upon the withdrawal of the needle the 
skin should again be washed with alcohol, and a piece of zinc oxid 
plaster, one inch square, applied over the site of the injection. Under 
these precautions regarding cleanliness there has never been, in my ex- 
perience, a suggestion of a local infection. Wherever the site of the 
injection, care should be taken not to plunge the needle into the muscle, 
but having drawn up the skin between the fingers, to insert the needle 
horizontally. 

Late Injection. — Antitoxin should always be given in diphtheria, no 
matter how late in the disease the case may first be seen. In one case 
first seen by me on the sixth day, 11, 000 units were given. The child re- 
covered. In a similar case I would now give 20,000 units. In another 
case of laryngeal diphtheria in a boy five years of age who was first 
seen on the fifth day 10,000 units were given, with prompt recovery. 
In a similar case I would now give 20,000 units as the initial dose 
and repeat if necessary. I have used the antitoxin as late as the eighth 
day of the disease, with resulting benefit or recovery, and it is my belief 
that the patient would not have recovered without antitoxin. In or- 
der to be signally effective, the serum should be given not later than 
the third day. The later it is given, the greater the amount required, 
and the greater the need of repeating the injection. 

Immunization and Quarantine. — When a member of a family becomes 
ill with diphtheria, the suggestions for quarantine (p. 649) should 
be carefully followed. In every case of diphtheria other children of 
the family should be immunized. Less than 1000 units should never be 
given for this purpose, regardless of the age of the child. Cultures 
should be taken from the throats of children and adults alike. If the 
Klebs-Loffler bacillus is found, the carrier must be isolated and treated 
as diphtheric, so far as quarantine is concerned. Two of my cases 
developed diptheria after immunizing doses of antitoxin. A child 
nine months of age was given 3000 units and developed diphtheria four 
days afterward. This patient recovered after a second injection of 
3000 units. A boy four years of age was given 1000 units for im- 
munization. He developed diphtheria in thirty-six hours, which was 



DIPHTHERIA 635 

controlled by the injection of 3000 units. The throat was clear in 
forty-eight hours after the second injection. 

Urticaria, — In 20 per cent, of my cases urticaria followed the use of 
antitoxin. The earliest appearance of the eruption was on the fifth 
day following the injection; its latest appearance, on the twenty-first 
day. The urticaria apparently differs in no respect from that due 
to other causes, and the treatment should be the same. Among 
local applications, a 1 per cent, solution of carboHc acid or a lead 
and opium wash reheves the itching better than do other measures. 
For internal administration, salicylate of soda answers better than 
any other form of medication. To a child five years old three grains 
well diluted may be given every two hours until five doses have been 
taken, and this treatment may be repeated every day until the rash 
disappears. 

Remedial Measures Other Than Antitoxin. — Of the many remedies 
which have been advocated and used from time to time in the treat- 
ment of diphtheria, practically none remains in use at the present time. 
During the pre-antitoxin period I had abundant opportunity, in 103 
cases at the New York Infant Asylum, to test the value of drugs, in- 
halations, vaporizing treatment, local applications, gargles, and sprays. 
In an article relating to this epidemic of diphtheria which I wrote 
several years ago is the following statement: ''The death-rate in the 
institution from diphtheria was large — about 60 per cent, mortality. 
In so far as the methods of treatment were concerned, all were equally • 
valueless. The mild and some moderately severe cases recovered 
under good general management. The severe cases died regardless 
of treatment." In other words, there was no method or scheme of 
treatment used at that time that was of any signal value. Happily, 
at the present time, all the old methods are forgotten. They are not 
needed. Antitoxin is a specific. The use of sprays and gargles and 
applications is of value as a means of cleanliness only. For this pur- 
pose the throat irrigation (p. 278) answers better than any other means. 
Forcible irrigation of the nose should not be employed. In such cases 
the danger of forcing infected material into the Eustachian tube, with 
resulting secondary otitis, is real. In small children, if the breathing is 
interfered with because of membrane or tenacious secretions in the nose, 
a few drops of hquid aibolene instilled every hour will give as much 
relief as can be furnished by any other local measure. 

Sick-room Regime. — In the management of diphtheria the same 
sick-room regime should be enforced as in other serious diseases. The 
temperature of the room should never be above 70°F., and at aU 
seasons of the year there should always be a free communication with 
the outer air by means of an open window. The child should wear the 
customary night-clothes, and the bed-clothes should be of the same 
weight as those used in health. 

Nourishment. — The nutrition of the patient is most important. As 
a rule, food is poorly taken because of the pain caused by swallowing. 
Inasmuch as but a few ounces may be taken at one time, the nourish- 



I 



636 



THE PRACTICE OF PEDIATRICS 



merit may well be given in as concentrated a form as possible. Milk 
should be given as the chief article of diet, with the addition of lime- 
water or bicarbonate of soda. If the taste of milk is disagreeable to 
the patient, it may be mixed with equal parts of a thick gruel and well 
salted. Animal broths possess so httle nutriment that their use is 
unwise. The milk, plain or diluted, will often best be taken if given 
cold or cool, even to children under one year of age. Fluid will usually 
also be taken from a spoon or cup better than from a bottle, because 
of the discomfort produced by drawing on the nipple. When sufficient 
nourishment will not be swallowed, gavage (p. 790) or rectal aUmenta- 
tion assists temporarily in maintaining nutrition. The temperature is 
rarely high enough to require the use of any means for its reduction. 
In case of high fever the sponge-bath or cool pack (p. 777) will answer 
the requirements. 

Heart Stimulants. — When the heart action becomes weak, irregular, 
or intermittent, stimulation will be necessary. For this purpose three 
drugs are of signal value — strychnin, tincture of strophanthus, and 
alcohol. 

Laryngeal Diphtheria. — ^Laryngeal diphtheria may develop coinci- 
dentally with a tonsillar or faucial diphtheria. The laryngeal inflam- 
mation may develop secondarily after a day or two of illness, or 
it may be the first manifestation of the infection. When a child ill 
with faucial or tonsillar diphtheria develops a hoarse or croupy voice, 
with or without impeded respiration, almost invariably the larynx 
has become involved. 

Differential Diagnosis. — When, in the event of a hoarse, croupy 
voice with obstruction as the manifestation of illness, and no membrane 
is visible, it is by no means easy to determine whether the case is one of 
membranous laryngitis or acute catarrhal laryngitis. The following 
suggestions have aided me not a little in arriving at a right conclusion : 



Diphtheric Membranous Croup 

Gradual onset. 

Obstruction persistent, with gradually 
increasing severity. 

Obstruction both to inspiration and ex- 
piration. 

Little or no response to emetics or in- 
halations. 

No response to sedatives. 



Catarrhal Croup 
Obstruction intermittent. 
Sudden onset. 

Obstruction to inspiration, but little to 
expiration. 

Response to emetics and inhalations 
and to sedatives. 



The mode of onset is, of course, not to be relied upon absolutely in 
differentiation. Occasionally the onset of catarrhal laryngitis may be 
gradual, while that of diphtheria may be sudden. In the consideration 
of a great many cases, however, the points of differentiation are of suffi- 
cient value to warrant the attention which has been given them. A 
particularly valuable sign of diphtheric involvement is the obstruction 
to expiration as well as inspiration. In catarrhal croup there is obstruc- 
tion to inspiration only. 

Treatment. — A safe rule to follow, in view of the urgent demand for 
early injections of antitoxin, is the same as in other forms of diphtheria, 



DIPHTHERIA 637 

i. e., when in doubt, inject 20,000 units. From the gradual cessation 
of the laryngeal symptoms it is fairly safe to assume that the child 
is doing well, although the breathing may not be entirely free for 
forty-eight or seventy-two hours after the first injection. In cases 
which require intubation 20,000 units should be given for the first 
injection and repeated the following day. According to my observa- 
tion, intubation cases require from 20,000 to 40,000 units, even when 
antitoxin is used early, by which we understand on the second or third 
day of the disease. The earlier the injection, the less frequent will be 
the necessity for its repetition. 

Nasal Diphtheria. — There are two distinct types of nasal diphtheria 
— the acute and the chronic. 

The acute cases resemble in all respects those of diphtheria as it 
occurs in the throat or larynx with the accompanying clinical mani- 
festations of illness and prostration. There may be membrane elsewhere 
and in many of the cases involving the throat and larynx the nares 
are also involved. At autopsies, before the advent of antitoxin, I have 
repeatedly seen the nasal passages plugged throughout their entire 
extent, the membrane being continuous from the anterior nares to 
beyond the first bronchial bifurcation. 

In what may be looked upon as the strictly nasal cases, the mucous 
membrane of one or both nasal passages only is involved. 

Symptomatology. — A symptom pointing strongly to a Klebs-Loffler 
infection of the mucous membrane of the nasal passages is a persistent 
excoriating mucous discharge, with or without a tinge of blood. The 
fever, prostration, and other evidence of the infection may be as severe 
as when the membrane is elsewhere located. 

Diagnosis. — The diagnosis is made by the appearance of the per- 
sistent excoriating discharge, by the discovery of false membrane in 
the nasal cavities, and by the finding of the Klebs-Loffler bacillus in 
the nasal discharge. 

Treatment. — The treatment is with antitoxin, as suggested for the 
tonsillar and faucial cases. 

Persistent Nasal Infection with the Klebs-Loffler Bacillus. — Per- 
sistent nasal infection of a mild type is of much more frequent occur- 
rence than is generally known. These cases are sometimes alluded to 
by writers under the term ''chronic nasal diphtheria." 

Symptoms. — The child has a persistent nasal discharge from one or 
both nostrils, but shows no sign of illness other than that occasioned by 
the persistent rhinitis. Since there are no systemic effects, these are 
not cases of diphtheria in the accepted sense of the term. Ulcerations 
are occasionally produced, and there may be destruction of membrane, 
cartilage, and bone. 

Illustrative Cases. — Case 1. — A girl of eight years of age was brought to my office 
because of a nasal discharge associated with considerable obstruction. The child 
had been ill for about one week, and had been treated for grip by home means. 
There had been slight fever and little or no prostration, but a serous nasal discharge 
which was bloody at times. There had been one or two severe nasal hemorrhages. 
An examination of the nasal cavities disclosed that both were filled with membrane, 



638 THE PRACTICE OF PEDIATRICS 

pus, and blood. Nasal diphtheria was at once suspected, and a culture was made 
which was negative. During the following three days six cultures in all were made 
and examined by three different bacteriologists in three laboratories, and all reports 
were negative for the Klebs-Loffler bacillus. The membrane was removed on two 
occasions, and there were three fairly severe nasal hemorrhages while we were try- 
ing to determine the nature of the infection. Various local measures were em- 
ployed without in any way influencing the process. After observing the case one 
week, during which time the child remained free from constitutional disturbance of 
any nature, I gave 5000 units of antitoxin. In twenty-four hours the nose was 
clear and only a considerable erosion on the septum remained, which promised to 
give trouble because of its depth and tendency to bleed. This area was cauterized 
and healed promptly, and the child was then well. 

Interesting is this case in view of the cultural absence of the Klebs-Loffler 
bacillus, and the prompt response to antitoxin, which proved beyond doubt that' 
the case was one of diphtheria. 

Case 2. — A strong, robust boy, twelve years old, from a New York suburb, con- 
sulted me solely on account of inability to breathe through his nose and a nights 
cough which was quite severe. Examination of the nose showed it to be filled with 
crusts, pus, and dried blood. Upon removing the obstruction a bleeding surface 
was left on both sides, and a perforation of the septum, the size of a dime, was found 
posteriorly. A culture was taken and showed a pure growth of the Klebs-Loffler 
bacillus. Five thousand units of antitoxin were given. The condition immediately 
improved. Within four days the nose was free from the Klebs-Loffler bacillus. 
This condition had existed for at least a year, and the boy had been examined by a 
specialist. 

Case 3. — A girl four years of age became ill with fever, which persisted for thirty- 
six hours, when the attending physician noticed a swelling and edematous condition 
of the soft palate. On seeing the case forty-eight hours after the onset I found the 
swelling and edema still present, with considerable post-nasal discharge. At no 
time was membrane visible. A culture was taken which proved negative. Five 
thousand units of antitoxin were given, and the child made a prompt recovery in 
about forty-eight hours. While there is no direct proof that the child had diphtheria, 
the prompt recovery after antitoxin suggests this condition. The absence of cul- 
tural proof, in view of our experience in the fi,rst case recounted, does not signify 
that the infection did not exist. 

Case 4. — A mother consulted me concerning her two children aged 2 and 4 
years, both of whom had had a chronic cold in the head for six weeks. There 
was a persistent nasal discharge from both nostrils in each patient, serous in 
character, requiring several handkerchiefs daily. The children were entirely 
well aDd happy. A culture showed Klebs-Loffler bacilli in both patients. Five 
thousand units of antitoxin for each child controlled the discharge. 

Much remains to be learned regarding the Klebs-Loffler bacillus 
and its action upon the individual. The effects of this organism may- 
be entirely local. Every year in hospital work we see many of these 
cases. In private they are less frequently encountered. On the other 
hand, what is apparently the same organism, with the same morphologic 
characteristics, may produce not only local effects but the most pro- 
found systemic toxemia and death. 

In the cases with local manifestations, are we dealing with the Klebs- 
Loffler bacillus in an attenuated form, or is the infection of a different 
nature and due to another organism of the same family? Is it possible 
for the cases showing only local manifestations to transmit the disease 
to others with resulting systemic effects? I have never known of such 
an occurrence. 

Treatment. — In these cases usually one dose of 5000 units of anti- 
toxin is sufficient. In case the process is not controlled, this dose 
should be repeated. 

Intubation. — To the genius of the late Dr. Joseph O'Dwyer, of New 
York, is due the perfecting of this operation, which will forever stand 



DIPHTHERIA 



639 



as a monument to the inestimable service which he rendered to man- 
kind. The O'Dwyer intubation set (Fig. 88) furnishes us with the 
necessary instruments for the operation. Various modifications 
of the tubes, the introductor, and the retractor have been attempted 
from time to time by others, but the original perfected design of 
O'Dwyer has yet to be improved upon. 




Fig. 860— Extubator. 

Intubation of the larynx may be required in case of a retropharyn- 
geal abscess situated low on the posterior pharyngeal wall, edema of the 
larynx or acute laryngitis. The greatest usefulness of the operation, 
however, — that for which it was designed, — is to relieve the stenosis of 
laryngeal diphtheria. Before attempting to introduce a tube into the 
larynx of the living subject the physician should familiarize himself 
with the operation on the cadaver. In no other way can the procedure 
safely be learned. Attempts at intubations by the unskilled on the liv- 




Fig. 87. — Introductor with tube attached. 

ing subject can result only in laceration and other gross injuries to the 
parts. 

Indications. — When to intubate is a question puzzling alike to stu- 
dents and to many physicians. It has been variously answered, and 
many attempts have been made to formulate a series of clinical mani- 
festations the presence of which would render the operatiion necessary. 
Thus, it has been said to be indicated when there is a pronounced reces- 
sion of the suprasternal and infrasternal regions, and when, as a result 



640 



THE PRACTICE OF PEDIATRICS 



of stenosis, air enters the bases of the lungs but feebly or not at all. It 
may safely be said that intubation is never done too early, but it is very 
apt to be done too late— not too late in a great majority of instances 
to be of some service to the patient, but too late to be of the greatest 
possible service. My rule regarding intubation in laryngeal diph- 
theria is to intubate when I see that the child is wasting vitality in his 
efforts to carry on respiration. Intubation should not be postponed 
until he becomes exhausted in the struggle for air. Diphtheria is a 
disease in which every possible strength-unit must be preserved. 
Energy wasted in supplying air is an unnecessary waste, since O 'Dwyer 
has shown us how to introduce a tube into the larynx. 




Fig. 88. — O'Dwyer intubation set. 

Operation. — For the operation of intubation, the patient should be 
wrapped from his shoulders to his feet in a sheet securely pinned from 
top to bottom. The older and stronger the child, the more this is neces- 
sary (Fig. 89). The patient is held on the lap of the nurse, who passes 
her right hand around the child 's body. The child 's head rests on the 
nurse 's right shoulder, firmly held in position by her left hand. If the 
child be large and strong, a third person may be required to hold the 
head. After the gag is in position, the operator, with instruments and 
hands disinfected, holds the introductor in his right hand, locates the 
glottis with the forefinger of the left, and, using it as a guide, directs 
the tip of the tube into the larynx. He must be certain that the tip is 
properly placed before exerting pressure to put the tube into position. 
This can readily be appreciated by one who has practised on the 
cadaver. When the tip of the tube positively is engaged in the glottis, 



DIPHTHERIA 



641 



gentle pressure will put it into final position. Force should never be 
used, even when the tube is started right, for the child may require a 
smaller tube than his age indicates. This is rather unusual, however, 
as are the cases which require larger tubes than the age calls for. When 
the tube is easily coughed up, it is my custom to introduce the next 
larger size. With the tube in position, the obturator is quickly 
removed. I never trust to pressure on the shank of the introductor 
to disengage the obturator, but keep the guiding index-finger of the 
left hand on the expanded head of the tube in order to insure its 
remaining in position during the extraction of the obturator. 




Fig. 89. — Position for intubation. 

Results of Intubation. — After the operation the child who has pre- 
viously been struggling will take a deep inspiration and cough. One of 
the most welcome sounds to the operator is the sharp rattle produced 
by the passage of air through the mucus which has been forced into the 
tube. This tells him that the tube is in position and that speedy relief 
of the stenosis may be expected. The intubated child will usually 
cough vigorously for several minutes, and in so doing may bring up a 
quantity of mucus and shreds of membrane. I have often been as- 
tonished at the large pieces of membrane and the quantity of thick 
41 



642 THE PRACTICE OF PEDIATRICS 

mucus that can pass through the comparatively small lumen of the 
tube. In a few cases the presence of the tube in the larynx has caused 
such a persistent cough that a sedative was required to control it. 
Small doses of bromid of soda — four grains every half-hour for two or 
three hours, for a child four years of age — usually answer the purpose. 
The thread, looped and knotted, which has been attached to the tube, 
should be long enough to extend four or five inches beyond the lips. In 
case relief to the stenosis is not immediately perceptible after the opera- 
tion, or if the breathing is made more difficult, one may be sure either 
that the tube is not in position or, if in position, that it is plugged with 
membrane, or that membrane may have become disengaged and is 
pushed downward ahead of the tube. A tube in the esophagus, where, 
in my hospital service, I have seen it placed by interns, may exert 
sufficient pressure upon the posterior portion of the larynx effectually 
to impede respiration. 

Illustrative Case. — Several years ago I was called to intubate a boy two years 
of age who was suffering from moderate stenosis due to diphtheria. The tube was 
easily introduced, but its introduction was followed by entire cessation of respira- 
tion. The tube was immediately extracted by means of the attached thread and 
was found to be plugged with membrane requiring considerable pressure with a 
wooden toothpick to dislodge it. The stenosis was somewhat reheved as the 
result of dilating the parts and a removal of a portion of the membrane, but not 
sufficiently to furnish permanent relief to the patient. The tube was again intro- 
duced, followed by a complete relief of the stenosis. 

Displacement of the Membrane. — When membrane is dislodged and 
pushed ahead of the tube, it will usually be expelled by coughing after 
the extraction of the tube. 

Illustrative Case. — A case of this nature, following the withdrawal of the obtura- 
tor, occurred in a child six years of age, whose breathing, before difficult, was im- 
possible. : The child struggled violently, became much excited, and with one hand 
free, knocked the gag from its mouth. In my efforts to extract the tube the string 
broke, and while introducing the gag in order to use the extractor, the child's strug- 
gles and attempts at coughing dislodged both the tube and a large amount of 
membrane, one piece of which, inclosing the tube, came out as a perfect cast of 
the larynx and upper trachea. The relief was immediate. Reintubation was not 
attempted, nor was it later necessary. The child had been given 5000 units of 
antitoxin twenty-four hours before, which helps to explain the dislodgment of the 
membrane. 

Removal of the Tube. — When the patient is progressing satisfactorily, 
the question arises: How soon may the tube be removed? I rarely 
remove it before the fourth day after intubation. I find that when it 
is taken out on the second or third day, for cleansing or other purposes, 
it must usually be replaced. 

Necessity for Intubation. — With the introduction of antitoxin, the 
necessity for intubation has become less frequent. The free use of anti- 
toxin, — 10,000 to 30,000 units as an initial dose, — given with the first 
sign of obstruction, and repeated at eight-hour intervals until two, three, 
or more doses have been given, will render intubation a still rarer neces- 
sity. I do not feel safe in these cases until 15,000 or 20,000 units have 
been given. Fortunately, in laryngeal obstruction due to diphtheria 
the stenosis is usually of gradually increasing severity, so that by the 



SCARLET FEVER (sCARLATINA) 643 

early use of antitoxin many cases are relieved before the necessity for 
operation arises. 

SCARLET FEVER (SCARLATINA) 

Scarlet fever has been clearly recognized for many centuries although 
its early history is exceedingly obscure. The disease has always been 
most prevalent in civilized portions of the world, has shown remarkable 
differences in the severity of its separate outbreaks, and in almost all 
instances notably refrained from attacking a certain proportion of 
exposed individuals, in this respect contrasting sharply with measles, 
which exhibits no such selectiveness. 

Jurgensen has reported an epidemic which in the years 1873 to 1875 
ravaged the Faroe Islands, where for at least half a century the inhabi- 
tants had not been exposed to the disease and where the geographic 
conditions rendered observations on its course unusually easy. Here 
the discovery was made that, from a population comprising all ages and 
certainly not protected against scarlatina by a previous attack, only 
38.3 per cent, suffered from the epidemic, whereas a similar study of 
measles in the same locality showed that 99 per cent, of the population 
unprotected by previous infection were attacked. It was furthermore 
observed that the susceptibility to scarlet fever was about seven times 
greater in persons under twenty than in those over forty. 

The records of certain European epidemics exhibit a mortality as 
high as 30 per cent., contrasting with a rate as low as 3 per cent, for the 
same place at another period. In New York State scarlet fever easily 
ranks among the dozen most prominent causes of death, usually causing 
a comparative mortality of five, to four of measles and six of typhoid. 

Recent studies of the disease have been devoted extensively to a 
search for the specific cause, our ignorance regarding which is now the 
most serious obstacle in the management of cases. 

Etiology. — The specific etiologic factor in scarlet fever has not yet 
been isolated. It is apparently present in the blood, throat, desquamat- 
ing scales, and discharges from complicating otitis and other suppura- 
tions. Inclusions in the polymorphonuclear leukocytes have recently 
been described as found in 30 cases of scarlet fever by Dohle, and con- 
firmed by Kretschmar and by NicoU and Williams. The inclusions 
would seem, however, to be non-specific, since they are present in cases 
of other streptococcal infections. 

Positive inoculations of scarlet fever into chimpanzees have been 
reported by Landsteiner, Levaditi and Prosek, and positive experi- 
ments with lower monkeys by Bernhardt. These results, as yet, 
lack confirmation. 

Bacteriology. — Streptococci are found in the throat almost invari- 
ably in the early stages of scarlet fever, and they may be present in the 
blood and lymph-nodes late in the disease or after death. Kolmer's 
studies show that the streptococci found in scarlet fever are not specific 
in their serum reactions, and Weaver found that they are morphologic- 
ally and culturally like streptococci isolated from lesions other than 



644 THE PRACTICE OF PEDIATRICS 

those of scarlet fever The role of this coccus is probably that of a 
secondary or accompanying invader, causing or increasing the sup- 
purative complication. Mallory has recently found a Gram positive 
bacillus at the seat of the primary lesion in cases of scarlet fever, and 
calls the organism B. scarlatinal. Definite proof of its etiological 
relationship to the disease is lacking. 

Transmission. — Scarlet fever is usually transmitted through asso- 
ciation of the diseased .with the unprotected. There seems to be sub- 
stantial ground for the belief that the contagion may be carried by an 
intermediary. This probably is of rare occurrence. Milk may be 
a means of conveyance. 

Contagion. — It has been proven that it is among the least con- 
tagious of the contagious diseases. I have repeatedly known a child to 
develop scarlet fever in a ward with several others, none of whom 
later developed the disease, as they were confined to their beds, and 
consequently kept from any immediate contact with the patient. 

The most contagious period is during the first three or four days of 
the illness. The danger of transmission during the period of desquama- 
tion is much less than is generally believed. Since little or nothing of 
the nature of the infecting agent is known, it is not wise to make defi- 
nite statements respecting the period of communicability. My obser- 
vation, however, in a great many cases in institutions and in private 
work, leads me to believe that the desquamation will some day be 
proved to be seldom, if ever, a carrier of the disease. Of late, many 
authors are inclined to place less emphasis upon the possible conta- 
gion from cutaneous scales and more upon the infective character of 
the nasal and aural discharges. 

Evidence is at hand showing that books, clothing, flowers, and food- 
stuffs are means of conveyance from the diseased to the unprotected. 
From my own observation, I have never known of a case having been 
contracted in any of these ways. I have, however, seen a great many 
cases of scarlet fever which, ordinarily, would have passed undiagnosed 
if the patient had not been suspected because of exposure. I see cases 
frequently in which a positive immediate diagnosis is quite impossible. 

Illustrative Case. — During the visitation of scarlet fever to a family, four chil- 
dren were attacked. Dr. S. Finley Bell had treated the two other members of the 
family at Englewood, a suburb of New York. A trained nurse caring for the chil- 
dren contracted the disease and died. Later, a girl six years old died with the 
disease. On one of my visits to one of the children who had been sent to New 
York city and later developed the disease, a member of the family called my atten- 
tion to the arms of the laundress, which were slightly reddened. It was Monday 
morning and she was washing. She had no temperature, a normal throat, no rash 
except upon the arms, and felt well and was annoyed that she should be disturbed 
in her work. The redness of the arms disappeared after the completion of the 
washing, and nothing further was discovered until two weeks later, when she was 
found to be desquamating profusely on the hands and feet and slightly over the 
body generally. She was sent to the Willard Parker Hospital, where she required 
two weeks to complete the desquamation. Here was a case in which a most care- 
ful search failed to reveal any conclusive evidence of scarlet fever, and yet the 
woman had the disease at the time of examination. 

There is strong probability that many of the cases of obscure origin 



SCARLET FEVER (sCARLATINA) 645 

are contracted by exposure to such atypical cases, rather than through 
infected milk, books, articles of clothing, or intermediary human 
carriers. 

Susceptibility. — The most susceptible age is from the second to the 
twelfth 3^ear. Cases occurring in children under one year old are rare. 
The very j^oung appear to possess a distinct immunity. 

Illustrative Case. — During an epidemic at the New York Infant Asylum at Mt. 
Vernon, N. Y., a colored boy was found to have the disease in a very active form. 
The institution was built on the cottage plan and this boy, 28 runabout children, 
and 4 nursing women orderlies with their 4 nurslings occupied the ward on a second 
floor in one of the two-story cottages. The institution, comprising 400 children 
and about 200 women, was crowded. 

To break up the ward would have meant that the exposed children, some of 
whom would probably develop scarlet fever, would be placed with unprotected and 
unexposed children. It was, therefore, decided to quarantine the ward with its in- 
mates. Every child in this ward developed scarlet fever except the four nurslings, 
who at the time of the outbreak were under three months of age. Three of the 
women also escaped. The fourth woman developed the disease and had a mode- 
ratelj^ severe attack, during which time she nursed her infant, which remained well. 
It is of interest that so effective was the quarantine that the disease did not spread 
beyond the ward in which it developed. 

Second Attacks. — One attack almost always protects from subse- 
quent attacks. I have seen but two undoubted instances of a second 
attack, one of which occurred after an interval of four months in a boy 
of six years, the child dying on the fifth day of the illness ; the other in a 
girl twelve years of age, whose previous attack was four years earlier. 
In the girl the second attack ran a typical but uneventful course. 

It is interesting to note that an unprotected individual may be 
repeatedly exposed and only at a late period develop the disease. Thus, 
during an intern service in the institution referred to, where I cared for 
108 cases of scarlet fever, and the epidemic was severe, requiring that 
many children be seen several times a day, three months of daily and 
sometimes hourly exposure transpired before the unmistakable signs 
of the disease became manifest in me. 

Incubation. — The period of incubation is variable. It is rarely less 
than five days. If an exposed child passes the ninth day in safety, the 
disease will probably not develop later. I have known one case to 
develop after tw^elve days' exposure, and one on the fourteenth day 
following exposure. So long a period of incubation, however, is exceed- 
ingly rare. Cases reported as developing after a very long exposure, — 
three to four weeks, — result from later exposure which was not known. 

Symptomatology. — Nearly all the characteristics of the disease are 
subject to wide variations. Even the rash, the most constant symp- 
tom, may be simulated by sepsis or produced by drugs. Among the 
diseases of children which we are called upon to treat there is, further- 
more, none other which may present itself in such unusual and peculiar 
ways. 

The three symptoms upon which some reliance may be placed are 
fever, angina, and the rash. Any one of these, however, may be absent 
in the mild cases. In the moderately severe cases the onset is usually 
abrupt, with fever, angina, prostration, and vomiting, and after twenty 



646 THE PRACTICE OF PEDIATRICS 

four to twenty-eight hours the developing rash, which is usually 
fairly characteristic. The angina causes a diffuse redness of the mucous 
membrane of the fauces and tonsils, and on the soft palate above the 
uvula minute red points become visible which may coalesce, forming 
diffuse, small, injected areas, and producing a blotched appearance. 

There is loss of appetite and always thirst. The child is irritable, 
and if old enough, complains of headache and muscle soreness. The 
temperature furnishes a fairly accurate index of the severity of the dis- 
ease. The mild cases have little fever, while the severe cases almost 
always have a high temperature. Thus a temperature range from 103° 
to 105°F. will usually be accompanied by a well-marked rash and pros- 
tration, which tell us that the poisoning is severe. When the tempera- 
ture remains above 103°F., the child is very uncomfortable and com- 
plains much of itching. 

The eruption remains at its height from two to six days, which may 
be looked upon as the period of the rash. With a subsidence of the 
rash, the temperature falls gradually to normal. 

Desquamation. — Coincident with the fading of the rash the des- 
quamation usually begins. It may be delayed, however, from this 
time until the third or fourth week. In a very few cases I have known 
the rash to last longer than the tenth day. It may show great irreg- 
ularity in its duration. 

Illustrative Case. — During our epidemic of scarlet fever every child in the in- 
stitution was carefully inspected three times daily. At 5 p. m., the time of the last 
inspection for the day, a boy of two years had a temperature of 102°F., an unmis- 
takable rash over the left buttock and thigh, and some redness of the throat. There 
was but little prostration. He was quarantined, and six hours after his isolation 
the rash faded absolutely. His fever promptly subsided on the same day. In 
spite of the suspicion of a mistake in diagnosis, inasmuch as he had been placed in 
a scarlet fever ward and exposed, we had to keep him there. Greatly to our 
surprise, on the tenth day free desquamation began. 

When uncomplicated, the average case goes on to recovery, with 
completed desquamation in from two to four weeks. 

The shedding of dead epidermis may be most variable in its mani- 
festations. I have seen the skin of the hands and feet shed like a 
glove ''en masse," and I have seen one case in which the rash was 
equally well marked in which there was no desquamation of any nature 
at any time. There has been desquamation, however, although it may 
be very slight, in nearly all scarlet fever cases coming under my obser- 
vation. There may be but slight peeling of the fingers and toes. 
The heel and the anterior aspect of the fingers and toes are the sites 
usually selected when the desquamation is scanty. 

Second Desquamation. — I have seen but two cases of second des- 
quamation. The first patient was a girl of five years, who completed 
the first desquamation and was free for six weeks, when the desquama- 
tion again occurred on the hands and feet and required three weeks for 
its completion. In the other case, that of a girl twelve years of age, 
the second desquamation appeared three weeks after the completion 
of the first. It involved only the feet and was. of two weeks' duration. 



SCARLET FEVER (sCARLATINA) 647 

The amount of desquamation bears a fairly definite relation to the 
severity of the rash, excepting in the anomalous cases. 

Severity. — The illness may be of the mildest type, and impossible of 
positive diagnosis, or it may be so severe that the child will live only a 
few hours. My shortest fatal case lasted thirty-six hours from the on- 
set of the symptoms. The child was never conscious after the first 
invasion, and the temperature was never below 106°F., nor could it be 
reduced below this point. 

Such cases as these, in which the system is absolutely overpowered 
by the scarlet fever poison, are extremely rare. The disease, when 
fatal, is usually so through its complications. 

It has not been my observation that the presence of wounds in any 
portion of the body renders a person more liable to scarlet fever. 

Diagnosis. — The diagnosis in many cases is very easy. In some it 
is difficult, and in others impossible. We have no positive means of 
proving our case clinically or bacteriologically. Not only are the mild 
cases difficult of diagnosis, but also the very severe cases. In malig- 
nant cases the patient may die before the development of characteristic 
signs, or the signs may be so masked by the severity of the infection as 
to render diagnosis impossible. 

Our means of diagnosis are the angina, which occasions a diffuse, 
intense general redness of the throat, the fever, and the diffuse blush of 
the skin, which in twelve or twenty-four hours develops into a diffuse 
punctate rash usually appearing first and most characteristically over 
the lower abdomen, in the groin, on the inner aspect of the thighs, and 
over the buttocks, and thence extending to, and involving, the entire 
skin surface. 

It has not been my observation that the rash first appears on the 
neck and chest, as has been claimed by different writers. The so-called 
strawberry tongue is of no differential value, for it may occur in many 
other forms of illness. 

Complications. — Probably no other disease of infancy or childhood 
is so fertile in serious complications as scarlet fever. In fact, compara- 
tively few die from the direct effects of the scarlet fever poison. A 
streptococcus infection of the throat is present in all cases of any degree 
of severity. This I have demonstrated in dozens of cases, and it is the 
throat as a culture field for the streptococcus that is the great source of 
danger in the disease. 

Membranous non-diphtheric angina has always been of streptococcal 
origin in my cases. On inspection, the exudation resembles that of 
true diphtheria and our only means of differentiation is the making of a 
culture. Such a membrane may involve the nasal passages, but rarely 
extends to the larynx. I have seen but two cases of membranous 
laryngitis of proved streptococcal origin, and these were not in scarlet 
fever patients. The local infection may be sufficiently severe to cause 
extreme necrosis. 

Illustrative Cases. — In one case I had been engaged to remove a pair of very 
large tonsils. This boy developed a very severe scarlet fever before the time 



648 THE PRACTICE OF PEDIATRICS 

appointed for the operation. On his recovery the throat was as free of tonsil 
tissues as if they had been carefully enucleated. 

In a fatal case necrosis of the soft palate occurred, resulting in a perforating 
ulcer larger than a dime. 

True diphtheria occurs as a complication in a very small percentage 
of the cases of scarlet fever. Before our knowledge of the Klebs- 
Loffler bacillus, much was heard of diphtheria as complicating scarlet 
fever, and this because of the presence on the tonsils of membrane, 
which we now know to be of streptococcal origin. 

Adenitis. — From the throat the glands may be infected. The 
lymphatic glands at the angle of the jaw and the retropharyngeal 
glands are, by reason of their location, the most frequently involved. 
Suppuration of the glands and abscess are very frequent results, and 
diffuse edematous cellulitis of the neck is an occasional result of such 
infection. 

Cases have been reported in which the pus burrowed into the medi- 
astinum, causing septic endocarditis and empyema. 

Pericarditis and endocarditis have been very rare complications in 
my cases, and have always been fatal, for the reason that such cases are 
always purulent, of streptococcal origin. I have had cases when it 
seemed that there must be an endocarditis, but which recovered entirely 
too promptly to have had this complication. In these instances there 
probably was an acute dilatation which had given ri«e to the murmur. 

Myocarditis of a mild degree is often present at autopsy. Lobar 
pneumonia is a very unusual complication. 

Bronchopneumonia is found at the autopsy in nearly all the fatal 
cases. The development of the disease during an attack of scarlet 
fever is of very grave importance. 

Otitis. — Otitis is a frequent and dangerous complication of scarlet 
fever. If all cases, the mild, the moderately severe, and severe, are 
included, it will be found in over 10 per cent. 

Albuminuria. — Early in the average case albumin will be found in 
the urine, if this is repeatedly examined and with sufficient care. This 
condition does not constitute nephritis, however, for albumin in small 
amounts will be found in most diseases of toxic origin in childhood. 

Nephritis. — Scarlatinal nephritis rarely appears before the third 
week of the disease. I have known cases to develop as late as the 
twelfth week after the onset. The nephritis is of the glomerular type, 
and more likely to occur after mild infections. The first sign will 
usually be that of a puffiness under the eyes and about the ankles. 
The urine becomes scanty and high colored. This complication will 
be referred to again on p. 655. 

Arthritis. — Joint complication has been present in but 5 per cent, of 
my cases. The arthritis is the manifestation of a local infection. 
There may be swelling and redness of two or more of the joints. The 
lesion has always been multiple; I have never known one joint alone to 
be involved. In some cases pain alone will be present, without either 
of the above symptoms. A fatal case of pyemic arthritis was seen by 



SCARLET FEVER (sCARLATINA) 649 

me in consultation with the late Dr. Mclnerny, of New York. The 
joints at the knees, ankles, elbows, and wrists suppurated. This child 
died. 

Mortality. — The niortality varies greatly. Different epidemics give 
a different mortahty. In institution epidemics the mortality is higher 
than in private hfe. In the New York Infant Asylum, during my 
service, the mortality in children under six years of age was 20 per cent. 
In private work the average mortality ranges under 10 per cent. 

Prophylaxis. — The most efficient safeguard is a normal throat. 
The presence of enlarged tonsils and adenoids doubtless increases the 
susceptibility to the disease, and their presence adds greatly to the 
dangers. 

Quarantine. — The isolation of those ill with contagious diseases is 
an absolute necessity for the protection of others. While it is advis- 
able in cases of scarlet fever to remove from the house children who 
have not had the disease, and, in the event of diphtheria, all children, 
regardless of previous attacks, such removal is often impossible. It 
then becomes our duty to establish such a quarantine as will be effective 
in preventing the transmission of the disease. In order to do this, the 
child and the attendant must not come in contact with other members 
of the family, whether children or adults. If the residence is a city or 
a country house, one or two rooms on the top floor should be selected 
for the patient, the room from which he was removed being carefully 
cleaned and disinfected. If the family occupy an apartment, an effect- 
ive isolation is more diflicult, but is by no means impossible. In such 
circumstances the room or rooms must be as remote as possible from 
the other living-rooms. The room in which the child is placed should 
be prepared for the patient according to the instructions laid down on 
p. 650. Not only should the attendant not come in direct contact with 
other members of the family, but there must be no indirect contact 
through dishes, feeding utensils, clothing, or bed-linen. The dishes, 
knives, forks, and spoons should be placed in boiling water and in this 
sent to the kitchen. The clothing, towels, and bed-linen should be 
placed either in boiling water or in a carbolic solution — one ounce to 
two gallons of water — before sending them to the laundry. Upon their 
arrival at the laundry they should be boiled at once. A chair outside 
the door of the sick-room may be used as a receptacle for the various 
articles for the patient, which are to be removed only when the person 
who brought them is at a safe distance. 

Two isolating rooms are better than one, and if there can be a con- 
necting bath-room, it is much more agreeable to the occupants. If two 
rooms are devoted to the patient, one is to be used for day and the 
other for night occupancy, the unoccupied room being freely ventilated 
after the removal of the child. Observing the above precautions until 
the child is well, I have repeatedly carried through to successful conva- 
lescence cases of diphtheria and scarlet fever while other unprotected 
children have remained in the household during the entire illness with- 
out taking the disease. 



650 THE PRACTICE OF PEDIATRICS 

An incident, previously referred to, which well demonstrates the 
value of proper quarantine, occurred at the New York Infant Asylum, 
Mt. Vernon, New York, during my service as intern in that institution. 
The institution was built on the cottage plan, two wards in a cottage. 
A colored child, an occupant of one of the upper wards, was discovered 
to be ill with scarlet fever. There was an extensive rash, considerable 
swelling of the cervical glands, and the whole aspect of the case was 
that of scarlet fever at its height. Through the negligence of an orderly 
the child had probably been ill two or three days before our attention 
was called to him ; as a consequence, 30 other children of the ward had 
been exposed. In order to prevent the spread of the disease to the 
other 400 children, it was decided to quarantine the ward with its 
children and the 4 attendants. This was done. Twenty-six children 
and one woman attendant developed the disease. The quarantine, on 
the plan above suggested, was continued for ten weeks. The thirty or 
more children on the ground floor of the cottage remained there as be- 
fore, but no other case developed in the institution. In order to pre- 
vent the spread of the contagion, there was no personal contact with 
those outside of the ward, except on the part of the physician who 
visited them daily, but who always went properly protected. All 
clothing and bed-linen were boiled before being removed from the ward. 
The dishes and feeding utensils were likewise boiled before being sent to 
the general kitchen. 

If such isolation is possible in an institution among the careless and 
more or less ignorant, it certainly should be equally effective among the 
intelligent, who are most interested in preventing the spread of disease. 

When the quarantine is raised, the child should receive a bath of 
hot water and thorough scrubbing with plenty of soap. A few hours 
later a bath of bichlorid 1:3000 should be given. If the hair is cut 
short and shampooed with green soap, followed by the bichloride, the 
disinfection is more complete. 

Treatment. — The patient must be kept in bed throughout the en- 
tire illness, of from four to six weeks ; i . e., from the onset, first manifested 
by sore throat and fever, until the desquamation is completed (see 
Quarantine, p. 649) . We must realize at the outset the possibilities due 
to the virulence of the infection and the complications. The death- 
rate in scarlet fever epidemics varies from 10 to 30 per cent. In greater 
New York from 350 to 450 children under ten years of age die from 
scarlet fever or its complications every year. In order to do our full 
duty to the patient we must place him in the best possible position for 
successfully combating the disease. 

The Sick-room. — The sick-room should be as large as it is possible 
for the family to supply. It is desirable that it be well lighted by two 
windows which will make free ventilation possible. For the latter 
purpose, the window-board (p. 138) answers well. There should al- 
ways be a direct communication with the open air, except when the 
child is being bathed or the clothing changed. Light and the free cir- 
culation of fresh air are absolutely necessary for the proper manage- 



SCARLET FEVER (sCARLATINa) 651 

ment of a severe case of scarlet fever. If possible, two rooms should be 
used — one for the daj-, the other for the night. The room which is not 
occupied should have the window or window^s wide open. When 
nephritis, endocarditis, or otitis develops, they are the result of the 
scarlet fever poison or associated infection, and not due to the fact that 
a window was left open. 

Clothing. — The child requires no extra jacket or wraps. The cus- 
tomary night-gown, with the light gauze undershirt and the usual 
bed-covering, is all that is required. 

Urine Examinations. — The urine should be examined for albumin 
every day. It is my practice to have the family get a few test-tubes 
and a bottle of chemically pure nitric acid. WTien the busy physician 
has the daily specimen sent to his office or carries it home himself, it is 
sometimes forgotten, misplaced, or lost. During convalescence, when 
the daily visit is not made, the nurse or some intelligent member of the 
family may be instructed to make the test and report if trouble is dis- 
covered.- Because of a lack of these precautions, nephritis may easily 
be overlooked until puffiness about the eyes and edema of the lower 
extremities are discovered by the attendant after albumin has been 
present in the urine for several daj^s. 

Diet. — In the bottle-fed during the acute febrile stage the food 
strength should be reduced one-half by the use of boiled water. If the 
child is getting eight ounces of a milk mixture, four ounces of this mix- 
ture should be given ^dih four ounces of water. For older children, the 
diet should be considerably restricted not only during the acute stage, 
but dming the entire course of the disease. During the acute febrile 
stage diluted milk, gruels, and orange-juice should constitute the 
diet. To a child from two to four years of age, 5 ounces of milk with 
5 ounces of barley gruel Xo. 2 (see formulary, page 70) ma}^ be given 
at four-hour intervals — -i or 5 feedings in twenty-four hours, which 
make an acceptable diet. Variations maj^ be made in the gruels used. 
Wheat, rice, and granum may all be brought into use, made as suggested 
in the formulary and given with equal parts of milk. It is always well, 
in the feeding of sick children, to provide for some variety in the food, 
in order that the child may not tire of it. The juice of one-half an 
orange may be given twice daily, three hours after the milk and the 
gruel feeding. For the sake of variety I occasionally allow a glass of 
whey or kumyss, or a glass of skimmed milk containing J^ ounce of 
limewater. Toasted bread, zwieback, or plain crackers, dry or in di- 
luted milk, may be given occasionally. 

Milk Diet. — The extensive milk diet in the management of scarlet 
fever, about which we have all heard and still hear a great deal, has not 
been so successful in my hands as has the foregoing, '^ly observation 
has been that the exclusive milk diet is apt to produce constipation, 
intestinal indigestion, coated tongue, loss of appetite — that, in fact, 
the child ''grows stale" on the milk, which is to be our dietetic main- 
stay during the weeks that are to follow. During the post-febrile 
period slight additions should be made to the diet by the use of farina, 



652 THE PRACTICE OF PEDIATRICS 

hominy, wheatena, and the Ughter cereals, prepared as porridge with 
a sprinkHng of sugar and a Uttle milk. The child's customary diet 
should not be resumed until four weeks have elapsed from the com- 
mencement of the attack. If the case has been a severe one, showing 
marked systemic infection, six weeks should elapse before the full diet 
is resumed. 

Bowel Evacuation. — There should be one evacuation of the bowels 
daily. If this does not take place, a soap-water enema should be given. 
If, on account of the diet and the recumbent position, there is a tendency 
to constipation, a glass of malted milk — 6 teaspoonfuls of the malted 
milk to 8 ounces of water — as a part of the evening meal will be of ser- 
vice in relieving the condition. The addition of one teaspoonful of 
cocoa will be acceptable when the taste of malted milk is objectionable. 

Laxatives, — As a laxative during the acute febrile stage, citrate of 
magnesia is very satisfactory. As a rule, children like it, and to those 
from two to five years of age it may be given in doses of from 2 to 4 
ounces. In case it is not well taken, from one to two teaspoonfuls of 
the aromatic cascara may be given. 

Specific Medication. — There is no specific medical treatment for 
scarlet fever. Many of my cases have passed through the entire illness 
without the use of any other measures than those suggested above. 

Serum Treatment. — The value of the serum treatment has been by 
no means demonstrated, and its use is not advised. The preparation 
of serum and its use before we know the nature of the scarlet fever 
poison is, to say the least, premature. The only use of therapeutic 
measures, so far as we know at the present time, regardless of the kind 
employed, is to assist the organism in battling with the disease. 

Nursing. — As the course of scarlet fever is distinctly cyclic in char- 
acter, much can be done in the most severe cases to prevent complica- 
tions and to relieve the patient of his temporary burden. Since one of 
the most important offices we have to perform is to keep the vital force 
at the highest possible point, we must do everything in our power to 
preserve the natural resistance of the patient, and this we have done 
in no small degree when we have so arranged for clothing, diet, fresh 
air, bowel evacuation, sleep, and quiet as to insure the child's comfort 
and well-being. The amount of vitality wasted by an uncomfortable, 
restless child in twenty-four hours may turn the case from a successful 
to a fatal issue. 

I fully believe in ''spoiling" a sick child. If a child is more at ease 
with the mother, the mother's place is with the child. If the mother's 
presence disturbs the child, as it does in some instances, she should be 
kept in the background. If it is apparent that the nurse selected is not 
to the child 's liking, or not adapted to the case, another nurse should be 
secured. I have been obliged repeatedly to take my best nurses from 
children gravely ill, because the patients were irritable and unhappy in 
their presence. 

Quiet. — Quiet is most necessary. One person only should be 
allowed in the sick-room with a child very ill. A second person is of no 



SCARLET FEVER (sCARLATINA) 653 

service, and if admitted, vitiates good air. Moreover, it is not to be 
expected that two persons of the ^'female persuasion" in the same room 
will not talk! 

Control of Fever. — I find it a safe rule not to allow the temperature 
to go much above 104°F. A higher temperature than this necessitates 
an overworked heart. For the purpose of controlling the temperature, 
a fifteen-minute sponging every hour with water at 90°F. may be tried. 

Packs. — If sponging does not answer, the pack (p. 777) should be 
brought into use. The mere existence of a rash is no contraindication 
to the application of moderate cold to the skin. The pack may be used 
in scarlet fever, just as in pneumonia or typoid fever. The fear that 
the disease may ''strike in" and kill the patient is one of the many 
inexplicable ideas of the laity with no foundation in fact. The child 
is placed in the pack at 95°F. It will rarely be necessary to reduce the 
temperature of the pack below 80°F. If the case is of the fulminating 
type, with persistent high temperature, the pack may gradually be 
reduced to a temperature of 70°F. In thus reducing the temperature 
the towel is not to be removed from the patient. He is turned from side 
to side and the towel moistened with water at the desired temperature. 
Time and again I have seen a child who was tossing about the bed, 
deUrious and sleepless, fall into a quiet sleep when placed in a pack. 
With a reduction of the temperature there is a corresponding diminu- 
tion in the pulse-beats of from 20 to 30 a minute. When we think 
what a saving this is to the work of the heart, the benefit is most 
apparent. 

Tub-haths. — The full tub-bath at a temperature of 95°F. for ten 
minutes at the commencement of a case in which there is a great deal 
of restlessness and irritability will often act most satisfactorily in quiet- 
ing the patient. Tub-bathing, however, requires a great deal of handl- 
ing of the patient, and in the cases in which there is persistent high tem- 
perature, and in those in which it mounts up suddenly after the bath, 
the pack is far the more satisfactory. In some cases with intense pros- 
tration and high fever and cold extremities, the warm bath — 105°F. 
to 110°F. — for ten minutes will have a most satisfactory effect. The 
fever is reduced, the child is quieted, and the heart action improved. 

Oil Inunction. — The itching and burning of the skin in scarlet fever 
is most distressing. This is relieved to a considerable degree by the 
pack. The child 's comfort wiU also be greatly enhanced by an inunc- 
tion twice daily of cold-cream or liquid albolene. Vaselin or olive oil 
may be used, but they are much less satisfactory. Vaselin will act as an 
irritant to some sensitive skins. 

During the period of desquamation the oily applications largely 
prevent a free distribution of the scales. 

Stimulants. — If during sleep the pulse is over 150 a minute, and the 
cardiac first sound is weakened, a heart stimulant is necessary. To a 
child one year of age one drop of tincture of strophanthus at two-hour 
intervals, or an equal amount of the tincture of digitahs, should be 
given. On account of its being well borne by the stomach, the tincture 



654 THE PRACTICE OF PEDIATRICS 

of strophanthus is always to be preferred. Strychnin is a remedy of 
considerable value as a heart stimulant. When the pulse is soft and 
the heart action shows a tendency to irregularity, J-^oo grain may be 
given every two to four hours to a child from one to three years of age, 
and }'i5o grain to a child from three to six years of age, at intervals 
of from two to four hours. Alcohol should be used only in the septic, 
asthenic cases when other means of stimulation have failed. In such 
instances it should be used freely. In a few cases I have used it in 
very large quantities with striking benefit. One-half dram of whisky, 
at first given every two hours, may be increased gradually until its 
beneficial effects are noticed on the heart action. It is astonishing 
how much alcohol may be given, in a profoundly septic case, without 
the slightest effect, except an improvement in the heart action, and a 
corresponding improvement in the child's general condition. 

Care of the Throat and Nose. — The throat and nose demand our 
attention during the acute stage. For the nose toilet in older children, 
a solution of menthol and liquid albolene may be used by means of an 
atomizer, and in the very young by instillation with a medicine-drop- 
per. Forcible syringing of the nose in a young child is not a safe pro- 
cedure even in the most skilled hands. Local treatment of the throat 
depends entirely upon its condition. If the mucous membrane is 
swollen, edematous, and covered with a glairy, mucopurulent secre- 
tion, if there is a psuedomembrane, or if there is much pain or discomfort 
upon swallowing, local treatment is required. The child should be 
made to gargle, if old enough; or, far better, the throat may be irri- 
gated with hot saline solution at 120°F. This is done in the manner 
described on p. 278. Force will be required with the very young. In 
older children the relief from pain that is experienced from free irriga- 
tion is so great that usually the child takes the tube in his mouth 
gladly for the future irrigations. The use of antiseptic gargles and 
washes has not seemed to me to possess any value other than that of 
cleanliness, and free douching acomplishes this in a far more satisfactory 
manner. 

Treatment of Complications. — Cervical Adenitis. — Cervical adenitis 
is a very frequent complication of scarlet fever, and when suppuration 
occurs, it is most troublesome. On the first appearance of a swollen 
gland, a cold compress should be applied and then kept on constantly day 
and night, until the swelling has materially subsided. 

The temperature of the water should be from 50° to 60°F. The 
compresses should be changed every thirty minutes during the day and 
at least every two hours during the night. Several thicknesses of old 
linen, such as are furnished by a table napkin, answer well as a 
medium for applying the cold. The material used should be cut of 
sufficient length to extend from ear to ear under the jaw. In order 
that the moisture may be retained, oiled silk or rubber tissue may 
be placed over the dressing, and over all a thin gauze bandage, which 
is pinned together on top of the head. 

Otitis. — Otitis is a complication in 10 to 30 per cent, of the cases of 



SCARLET FEVER (sCARLATINA) 655 

scarlet fever. In view of the grave possibilities of mastoid involvement, 
sinus thrombosis, and jugular bulb infection, the presence of pus in the 
middle ear should be promptly detected, and the pus evacuated by a 
free incision of the drum membrane. The presence of middle-ear 
infection may be suggested by a pain or a sensation of fullness in those 
old enough to locate it. In infants, restlessness, sleeplessness, or 
tenderness on manipulation in cleansing the ears may be the only ob- 
jective sign of the trouble. In the majority of my cases of otitis, none 
of the above signs of pain and discomfort were present. The ear in- 
volvement was suggested because of a continued elevation of tempera- 
ture which could not otherwise be accounted for. A persistent elevation 
of the temperature of unknown origin following scarlet fever is 
sufficient occasion for examination of the ears by an expert in otoscopy. 
As a routine measure during the fever, the condition of the drum mem- 
brane should be noted at least every second day. 

As stated above, otitis develops in from 10 to 30 per cent, of the 
cases, depending somewhat upon the character of the epidemic, but 
more upon the age of the patient. The younger the child, the greater 
the danger of ear involvement. Many cases of deafness which we meet 
have had their origin in an attack of scarlet fever, and are due to some- 
body 's ignorance or neglect. Among 185 cases of scarlatinal otitis 
reported by Bezold and quoted by Holt, in 30 there was entire destruc- 
tion of the membrana tympani; in 59, the perforation comprised two- 
thirds or more of the membrane; in 13, there were small perforations; 
in 44, there were granulations or polypi; in 15 there was total loss of 
hearing on one side, and in 6 of the cases upon both sides; in 77, the 
hearing distance for low voice was less than twenty feet. May, of New 
York, has collected statistics of 5613 deaf-mutes, of whom 572 owed 
their condition to otitis following scarlet fever. When we consider 
how many cases of permanent ear defects have occurred and do occur 
every year as a result of carelessness or lack of even an elementary 
knowledge of aural diagnosis, we do not feel inclined to congratulate the 
members of the medical profession on their abihty to complete their 
cases. The bacteriology of scarlatinal otitis is the same as in suppura- 
tive otitis developing with or following any other infectious disease, 
except that there is a greater tendency to severity because of the 
liability to streptococcus infection. Prompt relief demands prompt 
recognition of the condition of the drum membrane, with evacuation 
of the pus and suitable after-treatment. (See Acute Suppurative 
Otitis, p. 604.) This will not be possible if the practitioner does not 
examine the ears or is not sufficiently expert to recognize a diseased 
condition when he sees it. 

Cardiac Involvement. — Heart complications are not particularly 
frequent in scarlet fever. Nevertheless the heart should be examined 
daily. In my own observations, they have been present in about 2 per 
cent of the cases.. 

Nephritis. — Early in the cases of severe infection there will often 
be discovered a transient albuminuria with a few hyaline casts. There 



656 THE PRACTICE OF PEDIATRICS 

may be slight suppression of the urine. In but one of my cases was 
there complete anuria at this stage of the disease. Within thirty-six 
hours, however, after the first sign of the disease in this case, the 
kidneys ceased to act, and the child died on the third day, from the 
acute diffuse nephritis. The condition of the kidney giving rise to 
albuminuria is best relieved through attention to the skin function by 
the use of a bath at a temperature of 105°F. every six or eight hours. 
The child may remain in the bath for ten minutes, during which time 
the skin should be vigorously rubbed with the bare hand. The tincture 
of aconite in doses of one drop, with five drops of sweet spirits of niter 
for a child eighteen months of age, will usually produce a satisfactory 
skin action. 

What is known as scarlatinal nephritis rarely appears before the 
third week of the disease. I have known cases to occur as late as the 
sixth week. The management of this complication will be found on 
page 445. 

Arthritis as a complication of scarlet fever is seen in only a few of 
the cases — about 3 per cent. There may be swelling or redness of the 
parts, or both these symptoms may be absent. Whether or not the 
swelling is present, the joints are very painful on manipulation. Af- 
fected joints should be wrapped in old linen, saturated with lead and 
opium solution, and the dressing renewed every six hours. The follow- 
ing lotion has answered well in a few cases: 

I^ Mentholis 3ij 

Tincturae opii 3iv 

Spiritus vini recti q. s. ad 5 vj 

Soft linen is moistened with the lotion, wrapped about the parts, 
and covered with oiled silk or rubber tissue. The part affected is then 
wrapped in flannel or cotton- wool. The lotion may be freshly applied 
at intervals of from four to six hours. The only objection to its use 
is the odor of the menthol. 

Internally, to a child four years of age, aspirin may be given in doses 
of five grains, with ten grains of the bicarbonate of soda at four-hour in- 
tervals, four doses being given in the twenty-four hours. Salicylate 
of soda may be used in small doses ; but, as this may be badly borne by 
the stomach, aspirin is preferable. 

Surgical Scarlet Fever. — This type of scarlet fever is described 
in the text-books; a few writers strenuously maintain its existence, 
while others doubt it. An inoculation of the disease is supposed to 
take place through an abrasion or wound. I have never seen a case 
of true scarlet fever acquired in such a manner. I have seen surgical 
cases, however, develop a septic rash that could not be differentiated 
from the scarlet fever rash. In such patients the skin will desquamate 
on the body generally, but not on the hands and feet. There is no 
angina. Further, I have never known a case of this nature to transmit 
the disease to others. 



TYPHOID FEVER 657 

TYPHOID FEVER 

Typhoid fever is not a disease common to infants or very young 
children. Persons of any age may acquire the disease. It has been 
estabhshed that the fetus may be infected by the mother. Different 
observers have proved that bacilh in the fetal organs and blood have 
reacted to the Widal test. Numerous cases are reported as occurring 
during the first months of life, but the fact that these cases are reported 
singly, and that such reports are commented upon and quoted by other 
writers, emphasizes the statement that typhoid in the very young is 
extremely rare. In a large hospital and private experience, covering 
many thousands of cases of acute illness in children, during a period of 
nearly twenty-five years, I have seen but four cases of proved typhoid 
in children under two years of age. The youngest was eight months 
old, and another ten months old. 

Bacteriology. — Bacillus typhosus was described by Eberth in 1880 
and cultivated by Gaff ky in 1884. It is short, it does not retain Gram 's 
stain, and grows readily upon all ordinary laboratory media. The 
characteristic features of the organism are its viabiHty and its inability 
to produce gas in any sugar medium. The Bacillus typhosus enters the 
human body through the gastro-intestinal tract, usually by means 
of polluted water, which, in turn, may contaminate milk, vegetables 
and oysters. During the course of an attack of typhoid fever Bacillus 
typhosus may be cultured from the blood, rose-spots, feces, the urine, 
and exceptionally from the sputum. The bacilH are found in the 
blood in practically all cases of typhoid fever, most frequently during 
the first week, less frequently in each succeeding week. In the feces 
the bacilli do not, as a rule, appear until the second week, when 
ulceration has begun; they remain present until convalescence is 
established. The urine rarely contains typhoid bacilH before the end 
of the second week of the disease, when they are present in about 
25 per cent, of all cases. The urine may continue to show the bacilli 
for weeks or months after convalescence. In the gall-bladder the 
bacilli have been found years after an attack of typhoid fever. 

Bacillus typhosus is found in pus from complicating, suppurating 
lesions in typhoid fever, such as periostitis, osteomyelitis, synovitis, 
meningitis, peritonitis, and abscesses. 

Typhoid carriers are estimated by Russell to develop from about 
3 per cent, of all typhoid-fever patients. These persons may excrete 
the bacilh with the urine or feces for many years after an attack of the 
disease, and are, therefore, a menace to those about them. 

Immune bodies develop and circulate in the blood of the patient 
with typhoid fever. One kind of immune body is the agglutinin, 
whose presence is demonstrable by the Gruber- Widal reaction. This 
agglutination of typhoid bacilli by the diluted serum of a typhoid fever 
patient is not usually apparent until the second week of the disease, 
and may be delayed until the seventh week. The reaction is present, 
42 



658 THE PRACTICE OF PEDIATRICS 

however, some time during the attack in 95 per cent, of all cases of 
typhoid fever, and is, therefore, a diagnostic aid of value. 

Pathology. — The lesions produced by typhoid are usually much 
less severe in children than in adults. Autopsies upon youthful sub- 
jects have at times revealed no intestinal lesions sufficiently severe to 
warrant the diagnosis. In nearly all cases, however, the small intes- 
tine is the seat of a catarrhal process, and although there may be no 
actual ulceration, the solitary follicles and Peyer's patches are reddened 
and swollen. The spleen is almost always enlarged. Doubtful find- 
ings may be substantiated by cultures from the blood and intestinal 
contents. 

The details of the disease process have been well explained in the 
following paragraph from the work in pathology by Adami and 
Nicholls.* ^'According to Mallory, the essential feature of typhoid is a 
proliferation of the endothelial cells throughout the body, a change 
which he thinks is due to a diffusible toxin derived from the bacilli. 
The lesion in question is found in Peyer's patches, mesenteric glands, 
liver, and bone-marrow, as well as in the lymphatics and blood capil- 
laries, but is proportionately more intense the nearer to the point at 
which the infecting agent gained entrance. The endothelial plates 
attached to the fibrous meshwork of capillaries proliferate, become 
fused into plasmodial masses or giant-cells, and act as phagocytes. 
They ingest the bacteria and slowly eat up the lymphoid cells, which 
thus gradually disappear. A few leukocytes are to be seen in the 
follicles, and within the crypts of Lieberkiihn, but are not an important 
feature. Owing to the massing of these endothelial cells within the 
capillaries and the consequent obstruction to the blood-supply, the 
parts deprived of their nutrition undergo necrosis. The focal necroses 
in the liver and spleen are to be explained in the same way." 

Transmission. — Transmission may take place by different carriers, 
the principal ones being infected water, milk, uncooked vegetables, and 
shell-fish. That the disease is usually water-borne is admitted by all. 

Anti-typhoid Vaccination. — The prophylactic value of anti-typhoid 
vaccine has been abundantly established in both civilian and army 
practice. For an average child ten years of age one-half the adult dose 
should be given. Thus if 500 million is given for the first dose, 1000 
million for two subsequent doses at intervals of ten days, a total 
dosage for a child of ten years would be 1250 million. 

Reaction. — A reaction manifested by slight fever and muscle sore- 
ness and fatigue occurs in a small percentage of cases. The local re- 
action is slight, there may be pain, tenderness and a localized infiltrated 
area. The neighboring lymph-glands may show temporary enlarge- 
ment and be sensitive to touch. This condition need cause no 
anxiety. 

Symptoms. — I cannot agree with those writers who describe urgent 
symptoms early in a case of typhoid. 

The early manifestations in a great majority of cases consist in 
* Adami and Nicholls: Principles of Pathology, 1909, vol. ii, p. 439. 



TYPHOID FEVER 659 

moderate fever, becoming a little higher each day, apathy, and drowsi- 
ness. The tongue is coated and there is loss of appetite. 

In children systemic poisoning from intestinal sources appears to 
have some selective action on the nervous system; thus, disturbed di- 
gestion, whether acute or chronic, is productive of dreams and night- 
terrors. Gastro-intestinal disturbances, more than any other factor, 
are productive of convulsions. In typhoid fever the central nervous 
system, similarly, is affected. The child is dull and apathetic. So in- 
definite are the signs that a diagnosis is impossible for days, and often 
it is just this feature of absence of diagnostic signs that arouses a sus- 
picion of typhoid fever. Now and then a case is seen with stormy 
onset, high fever, delirium, and rapid pulse. In such cases there is 
usually an associated infection, such as an acute intestinal infection 
or one due to the pneumococcus. 

Nervous Symptoms. — In mild cases the nervous manifestations may 
be shght or altogether lacking, or there may be apathy, drowsiness, 
stupor, and delirium. The temperature range and the nervous mani- 
festations appear to bear little relation to each other; thus, with a low 
temperature range there may be pronounced stupor and delirium, sug- 
gesting the possibility of meningitis. 

The Pulse. — The pulse-rate is a most characteristic sign. It is com- 
paratively slow, decidedly out of relation to the temperature range — 
slower than in any other illness excepting meningitis. The pulse shows 
no irregularity in force or rhythm. I have seen the pulse at 110 with a 
temperature of 104°F. This, in itself, is a most suggestive sign. 

The Spleen. — The spleen is usually enlarged, the enlargement cor- 
responding with the severity of the attack. The organ is usually 
palpable some time during the second week, but in mild cases may 
never appear below the free border of the rib. 

Gastro-intestinal Symptoms. — Tympanites is the rule; this condition 
may be extreme or of mild degree, or it may not exist. With suitable 
feeding, this feature may be largely eliminated. 

Either diarrhea or constipation may be present; here also the feed- 
ing of the patient plays an important part. Patients who are fed with 
large quantities of milk will often have diarrhea or constipation, or the 
two conditions alternating, along with abdominal distention, high 
fever, and greater toxicity. 

Rose Spots. — Rose spots may be absent, few in number, or scattered 
over the skin surface. They appear most often on the abdomen; but 
frequently also on the chest and back. 

Duration of Immunity Conveyed. — According to the best observers 
immunity continues from 2 to 23^^ years, at the end of which time a 
re-inoculation should be undertaken. 

Advisability of Innoculating Children. — Children who remain at 
home under careful supervision will not require inoculation, as the 
incidence of typhoid under such conditions is very small. Those who 
travel about, particularly in summer, going by train or boat, living in 
hotels and boarding houses, are constantly exposed to the possibilities of 



660 THE PRACTICE OF PEDIATRICS 

typhoid infection. Such children should have the value of anti- 
typhoid vaccination. 

Temperature. — The temperature range is variable. In the case of a 
boy of ten years, who showed a positive reaction, the temperature 
lasted two weeks but was never above 100.5°r. by mouth. The usual 
range in my cases has been 101° to 103°F., perhaps occasionally reach- 
ing 104°F. It has been extremely rare for the temperature to con- 
tinue after the eighteenth day. My shortest temperature record was 
that of a ten-year-old girl, the duration of her fever being ten days. In 
typhoid a very high temperature is not always a bad prognostic sign. 

Illustrative Case. — In a girl whom I saw in consultation with Dr. Staub, of 
Stamford, Conn., there was a temperature range for eleven days of 104° to 106°F., 
and from 101° to 104° for ten days longer, the entire duration of temperature being 
thirty-six days. During the illness the child did not appear to be very ill. 

This observation has been repeated in other cases. 

Intestinal Hemorrhage. — Intestinal hemorrhage is very rare in 
children. Perforation I have never known. 

Complications. — The complications of typhoid in children have 
been exceedingly rare in my experience with the disease, and fatahties 
have been of most unusual occurrence. 

The fact that typhoid fever bacilli may be cultivated from the blood 
and urine implies that infection of various organs in the body may and 
does occur; thus the disease may cause pyeli tits, peritonitis, meningitis, 
osteomyelitis, synovitis, otitis, and abscesses. When broncho- 
pneumonia occurs with typhoid fever, it is usually a terminal infection. 

Suspicious Diagnostic Signs. — Apathy, drowsiness, a gradually ris- 
ing temperature-curve, with diarrhea and perhaps tympanites. 

Diagnostic Signs. — Positive Widal reaction; elevation of tempera- 
ture, and pulse slow in comparison to the temperature ; involvement of 
the central nervous system, drowsiness, stupor, delirium, enlarged 
spleen, and rose spots. 

The Widal test may be corroborated by culturing the blood and 
urine and by examination of the feces. 

Differential Diagnosis. — Any continued fever of unknown origin, 
until very recent years, would have been called typhoid or malaria. 
It was only a few years ago that some of our best clinicians in this 
country and in other lands diagnosed as typhoid every continued 
fever which did not respond to quinin, and for which no adequate cause 
could be discovered. 

With the exact means of diagnosis which are at our disposal at the 
present time there is no occasion for failure to differentiate malaria, 
typhoid, and the conditions with temperatures due to occult pus. 

The nervous phenomena of typhoid, when particularly pronounced, 
may, upon inspection alone, closely simulate those of meningitis. In 
typhoid the respirations, if slow, are regular and of even depth; the 
pulse is slow and regular. In meningitis irregularity or some atypical 
condition characterizes the pulse; it may be very rapid, — 180 to 200, — 



TYPHOID FEVER 661 

with a temperature of 101° or 102°F. The spleen is not enlarged in 
meningitis, nor are rose spots present. 

Acute miliary tuberculosis may simulate typhoid. In tuberculosis 
of this form there is absence of all signs excepting the fever, which is 
usually very high in children of the typhoid age. The eruption, and 
the mental dulness of typhoid, are not seen in acute miliary tubercu- 
losis. An enlargement of the spleen may be present in both diseases. 

Mortality. — Many of the mortality tables are valueless. Statistics 
of cases and diagjioses antedating the Gruber-Widal reaction and the 
discovery of the bacillus in the blood, urine, and feces are inaccurate. 
Thus, in one series, in infants under one year of age, we find the mor- 
tality given as 50 per cent. 

The mortality in private cases treated in homes or private institu- 
tions ranges from 2 to 3 per cent. In cases treated in hospital wards 
or in institutional homes it ranges from 8 to 10 per cent. 

In 95 hospital cases Kophk lost 9 patients — a mortality of 9.4 per 
cent. Henoch, in 375 cases, had a mortality of 14 per cent. 

Treatment. — While usually the disease runs a shorter course in the 
child than in the adult, an attack means, at the least, several days of 
illness, and it may means from three to six weeks. For this reason it 
is best to establish a sick-room regime, under which must be particularly 
considered the feeding, the bathing, the airing of the room, and the 
maintenance of absolute quiet for the patient. The bed-linen should 
be changed every day, and if the patient becomes very ill, but one at- 
tendant at a time should be in the sick-room. 

Bathing. — The typhoid patient should be sponged twice a day, an 
ordinary cleansing bath being given. During the bath, it is not neces- 
sary to uncover the body. Parts may be bathed and dried, after 
which other parts may be given attention. 

Mouth Toilet. — Careful mouth toilet should be observed. Gingivi- 
tis and ulcerative stomatitis, with secondary involvement of the cervi- 
cal lymph-nodes, are not infrequent comphcations of these cases. 

Care of the Discharges. — The discharges from both bladder and in- 
testine should be received in vessels containing a 1 : 1000 solution of 
bichlorid of mercury. Carbolic acid should not be used. The necessity 
for the attendants to wash their hands with soap and water after 
attending to the patient should be made very plain. Attendants should 
also be advised as to the proper disposal of the discharges. In children 
of tender age who still require the napkin it is best to dispense with the 
usual article and use cheese-cloth instead, several thicknesses of which 
may be made of the required shape and burned when soiled. 

The Feeding of Typhoid Fever Cases. — Contrary to the general prac- 
tice, I give little or no milk in typhoid cases. Early in my professional 
work I gave milk, which I had been taught afforded the only diet for 
the typhoid patient. I soon discovered that the less the milk given, the 
less was the tympanites. I found that without milk the temperature 
course was lower, that there was less tendency to delirium, that 
the duration of the case was shorter and, as a whole, less severe. In 



662 THE PRACTICE OF PEDIATRICS 

fact, my observations bear out the teaching of Seibert, of New York, 
who was the first to advocate the non-milk diet in typhoid fever. 

The diet which I now use consists largely of gruels, made from 
cracked wheat, barley, rice, oatmeal, or any of the uncooked cereals. 
I order one ounce of the cereal boiled for three hours in one pint of water. 
At the completion of the boiling, boiled water is added to make the 
quantity of the gruel one pint. If the gruel is too thick for drinking, 
more boiled water may be added. The gruel thus prepared is used as 
a ''stock." It may be given plain, with salt or with sugar, or both. I 
frequently add, as flavoring, two or three ounces of chicken or mutton 
broth. From six to eight ounces of t'he gruel are given every three 
hours — five or six feedings in the twenty-four hours. The patient is 
encouraged to drink water, which is given between feedings. Lemon- 
ade, tea, and weak coffee may also be given between the feedings. 
Rice or other light cereal, which has been boiled for at least four hours, 
is given once or twice daily. It is best served with plenty of butter and 
sugar. This with the view of increasing the caloric content of the food. 

The diet schedule for a typhoid patient, aged five years, would be 
practically as follows: 

6 A. M. : Eight ounces of gruel with sugar or a small amount of 

broth added. Zwieback or dried bread and butter. 
8 A. M. : A drink of weak tea with sugar, or the whites of one or 

two eggs with sugar in orange-juice. 
10 A. M.: Farina, cream of wheat, rice, served with butter and 

sugar, or maple-syrup and butter. Drink of weak tea or 

kumyss or matzoon, or perhaps a dried milk food, such as 

malted milk or Nestle's food. 
2 p. M. : Eight ounces of kumyss, matzoon, or skimmed milk 

diluted with gruel. Zwieback or dried bread and butter if 

wanted. 
4 p. M. : Orange-egg sherbet, or a drink of lemonade or tea and 

sugar. 
6 p. M.: Cereal (or gruel) with sugar and butter or with broth. 

If skimmed milk has not been given at 2 p. m., it may be given 

with cereal at this time. 
10 p. M. : Gruel with sugar or broth, or with wine. 

Later, when the tongue becomes clear and the breath loses its 
characteristic odor, scraped rare beef, and soft-boiled eggs may be 
allowed. With the use of the more substantial foods, the number of 
feedings in the twenty-four hours is to be reduced to four. 

It will be seen that the caloric requirements, 60 to 70 per kilo, for 
the five-year-old child, may easily be supplied by the above arrange- 
ments of the feeding, although the diet arranged may not be an ideally 
balanced one. It would be high in carbohydrates, rather low in fat, 
and perhaps deficient in proteid, particularly during the earlier period 
of the treatment. 

Fat in considerable quantity is poorly digested by young typhoid- 



TYPHOID FEVER 663 

fever patients. It may be given, however, in small amounts when 
mixed with other foods. Foods containing proteid should not be given 
in considerable amount until we can predict the course of the disease. 
Milk; scraped beef, and soft-boiled eggs are not well borne by young 
typhoid patients, and a temporary reduction of proteid is not felt by 
them. 

Carbohydrates, such as the cereals and the different sugars, are 
readily cared for when properly prepared and administered. They 
supply fuel, but no by-products, and do not require immediate elimina- 
tion from the body. Excessive emaciation is prevented through their 
action as proteid sparers. Mendel and Rose, in the Journal of Biological 
Chemistry, state that they found that the excretion of creatin induced 
by starvation is inhibited in rabbits by feeding a diet of carbohydrates, 
absolutely free from proteids and fats. When the carbohydrates are 
given in liberal amounts, the creatin entirely disappears from the urine. 
The creatin eliminated is not reduced by feeding a diet of fat alone or 
by a diet of fat and proteid. Experimental interference with carbo- 
hydrate metabolism leads to the elimination of creatin, the presence of 
the creatin being due to a true tissue, or endogenous metabolism. 

Milk should not be given in any considerable amount before the 
temperature has been normal for one week. Even then, in a case in 
which no milk has been given and in which there have been pronounced 
elevation of temperature and intestinal disturbance, the giving of milk 
may cause a rise in the temperature. In not a few cases in which the 
temperature was running a low course — from 100° to 102°F. — without 
the presence of tympanites or delirium, I have seen it shoot up to 
105. 5°F. and the tongue become furred and the abdomen distended 
as a result of the administration of milk. 

Illustrative Case. — A few years ago a girl, twelve years of age, had typhoid 
fever. The temperature was not high, the range being from 101° to 103°F. In 
fact, fever and an enlarged spleen were the only signs of the disease, until the 
diagnosis was confirmed by a positive Widal reaction. The tongue was moist 
throughout the illness, as is not unusual when milk is not given. The family were 
fearful that the patient was not being sufficienth^ nourished. The mother had 
been told by a physician, a family friend, that such was the case. She begged 
that I allow the girl one glass, eight ounces, of full milk daily. I immediately 
ordered the nurse to give the patient one glass of Walker-Gordon milk once in 
twenty-four hours. She did so, and in three hours after the first glass there was 
a rise in temperature to 106°F., with abdominal pain and distention. One bottle 
of the citrate of magnesia and a high enema were given, after which the disease 
resumed its usual course under the previous diet, without milk, the temperature 
not going above 99°F. after the seventeenth day. An uneventful convalescence 
followed. 

Mortahty statistics do not teach us all that may be learned regard- 
ing the disease or a method of treatment. The time element, as related 
to the duration of the illness and the duration of the convalescence, is 
important. My observation in the milk-fed cases is that the illness is 
more severe, increasing the danger to life, and that the duration of the 
illness is longer. Emaciation is much greater, and the convalescence 
is consequently much more protracted than under the feeding I have 
indicated. The case in which the temperature period is cut down to 



664 THE PRACTICE OF PEDIATRICS 

fourteen to twenty days, and in which there is Httle emaciation and a 
prompt convalescence, should not be put in the same class with the case 
in which the fever lasts from thirty to fifty days or longer, with a con- 
valescence of three or four months, although both patients have had 
typhoid fever and both have recovered. 

It is argued that milk constitutes the ideal diet, for the reason that 
it contains all the nutritional elements required by the organism, — fat, 
proteid, carbohydrate, and mineral salts, — which is the truth. It is 
further claimed that milk may be taken in large quantities and be 
readily digested, which is not true in the case of sick children. The 
addition of pepsin, hydrochloric acid, etc., has been of no value. I have 
learned that in order to have a short case and a mild case the abdomen 
must be kept flat. Tympanites is an indication of danger, regardless 
of how it is produced. On the milk diet, tympanites is the rule. On 
the mixed diet suggested it is the exception. So long as I can keep 
the belly flat I know that I have the case reasonably in hand. 

Drugs. — With the so-called intestinal antiseptics in typhoid fever, 
my experience has been most unsatisfactory, so far as concerns their 
influence upon the disease. If there is constipation, the citrate of 
magnesia, from four to six ounces, given cold, is grateful to the patient 
and usually proves effective If the bowels do not move once in 
twenty-four hours, a high enema should be given. The digestive 
capacity is indicated by the condition of the tongue and may be improved 
by the use of dilute hydrochloric acid and the tincture of nux 
vomica. The following will be suitable for a child from five to ten 
years of age: 

I^ Tincturae nucis vomicae gtt. xlviij 

Acidi hydrochlorici diluti gtt. cxx 

Glycerini . 5 iss 

Aquae destillatae q. s. ad 5iv 

M. Sig. — One teaspoonful in water after each meal. 

As many as four bowel passages in twenty-four hours may occur 
without harm to the patient. In fact, I consider from two to four nec- 
essary to maintain free drainage. When there are more than six in 
twenty-four hours, loose and watery in character, the loss of fluids sus- 
tained may be a serious factor in the case, in causing a concentration 
of the blood, w^th a corresponding concentration of the poison, as shown 
in the marked general toxemia. 

Diarrhea in typhoid is best controlled by the use of opium combined 
with bismuth. To a child from three to five years of age, the following 
may be given: 

I^ Pulv. ipecacuanhae et opii gr. x 

Bismuthi subnitratis (Squibb) gr. c 

M. Div. et ft. chart, no. x. 

Sig. — One every three hours until the stools diminish in frequency, 
then give at intervals of six to twelve hours if necessary. 

For children from one to three years old the dose of the Dover's 
powder should be reduced one-half, the full amount of the bismuth 
being given. The amount required to keep the diarrhea under control 



TYPHOID FEVER 665 

will soon be learned. Of course, constipation must not be produced, 
for if a free bowel action is interfered with, there will be increased pros- 
tration and higher temperature. 

Control of the Fever. — A temperature at or below 104°F. is not 
interfered with, in the great majority of cases. Of course, a very deli- 
cate child with a weakened heart action may require the use of anti- 
pyretic measures before this temperature is reached. This necessity, 
however, is unusual. My observation is that when the temperature is 
above 104°F., the patient does better if proper means are used for its 
control. 

Antipyretic drugs are rarely given. Quinin, in my cases, has 
never proved of the slightest value, even when given in large doses — 15 
or 20 grains in twenty-four hours to a child five years of age. The 
coal-tar products, such as phenacetin, may be used in small doses 
without harm, if hydrotherapy is not applicable, as in a case which 
I recently saw in a remote country district. 

Illustrative Case. — The patient was a boy six years of age. He was delirious at 
times, tossing almost constantly about the bed, and sleeping but little, with a 
temperature ranging from 105° to 106°F. The disease period was the latter part 
of the second week, and the patient was becoming rapidly exhausted. The parents, 
densely ignorant, refused to allow the bath or pack. Sponging, which was carried 
out indifferently, had not the slightest effect on the temperature and appeared to 
excite the patient. It was suggested to the attending physician that he give two 
grains of phenacetin and one-half grain of the citrate of caffein at intervals of three 
to six hours. From four to six powders daily were required to keep the fever 
within the desired bounds and the skin moist. This medicine had a decidedly 
quieting effect upon the patient, whose heart action was in no way unfavorably 
influenced and who made a complete recovery. Had the great restlessness, the 
loss of sleep, and the delirium continued I have no doubt there would have been 
a fatal termination. 

While there is much truth in what has been written concerning the 
depressing effects of the coal-tar products, and while the dangers from 
their excessive use are realized, on certain occasions they are a neces- 
sity. I cannot help feeling that the dangers have been exaggerated. 
Probably the diseases in which the use of such drugs is most dangerous 
are pneumonia and the inflammatory conditions of the heart. 

Heart Stimulants. — If the heart, by the rapidity of its action, shows 
signs of failure, the tincture of strophanthus is our best remedy. When 
there is irregularity in force and rhythm, strychnin should be used. A 
child from five to ten years of age may be given two drops of the tinc- 
ture of strophanthus at intervals of two to four hours. Strychnin, 
3^0 grain, at intervals of three to four hours, may be given for the same 
age. Alcohol should not be given as a heart stimulant until other 
means have failed. It is a drug to be used only in conditions of great 
stress. Its function is to carry us over and out of difficult places, and 
it may be given in the form of whisky or brandy, one to three drams at 
intervals of two to four hours in children from three to ten years of age. 
Its continued administration for a considerable period is not to be ad- 
vised. In any disease it is difficult to lay down definite rules for the 
administration of heart stimulants. They are used with the hope of 
producing a definite effect, and when such effects are produced, a larger 



666 THE PRACTICE OF PEDIATRICS 

quantity should not be given. It is best always to begin with small 
doses and gradually increase until the desired results are apparent. 

Hydrotherapy. — Pyrexia is best controlled by hydrotherapy. 

Sponging with lukewarm or cool water may be tried, and if the case 
is not severe, this may answer. The child may be sponged with water 
at from 80° to 70°F. for one-half hour out of every two or three hours. 
Sponging, however, even if it controls the temperature, may not be the 
best means of using water for this purpose, for the reason that many 
children object to it, and in consequence the sponging disturbs them, 
increasing their irritability and reducing their vitality. 

The use of the bath for the reduction of fever in children I have dis- 
continued. They invariably object to it, the bath excites or frightens 
them, and, as a rule, particularly in the very young and delicate, the re- 
action following it is poor. Moreover, the bath necessitates a great 
deal of handling, undressing and dressing, and therefore tires the 
patient. 

Reduction of the temperature by means of a rectal irrigation with 
cool water has its advocates. If the temperature is running high and 
intestinal lavage is indicated for reasons other than the temperature, 
lavage may be used here, the water being of a lower temperature than 
that of the body, though I never use it lower than 80°F. for this 
purpose. Without a high body-temperature, however, and other indi- 
cations as well, irrigation is never to be used. It causes straining, 
excites the child, and thus increases the danger of hemorrhage and per- 
foration. Furthermore, it is a very indifferent antipyretic, even when 
used with water as cold as 75°F. 

By far the best means of reducing the temperature in children is 
the cool pack (p. 777). Its advantages are that it causes no fright 
or shock, the child being disturbed comparatively little by it. He 
may be placed in a towel, which has been wet with water at 95°F., 
and the only manipulation necessary is to turn him from side to side, 
so that the towel may be kept constantly wet with cool water at the 
desired temperature. The pack more effectually controls the tempera- 
ture than does either sponging or the tub-bath. As suggested else- 
where (see p. 778), the child should be removed from the pack when 
his temperature falls to 102°F. 

Hemorrhage and Perforation. — Hemorrhage has not occurred in 
any of my cases in which the non-milk diet was given. In the event 
of hemorrhage the cold coil or the ice-bag should be applied and Dover's 
powder given in full doses to control peristalsis. In case of perforation, 
operative procedure is to be resorted to, but this holds out little hope. 
Children bear abdominal operations badly, and, considering the ex- 
hausted condition of a young child in the third or fourth week of a 
severe typhoid, the outlook is most unfavorable. 

MALARIA 
Malaria is caused by the Plasmodium malarise, a protozoon dis- 
covered by Laveran in 1881. 



MALARIA 667 

Species. — Three species of Plasmodium are recognized, that caus- 
ing tertian malarial fever, that causing quartan malarial fever, and 
that causing malaria of the estivo-autumnal type. 

The tertian malarial parasite, which is the most common form, com- 
pletes its development in the blood in forty-eight hours, and produces 
a malarial paroxysm every second day. When fully grown, the tertian 
parasite is much larger than the quartan variety, which sporulates in 
seventy-two hours. The estivo-autumnal parasite produces the remit- 
tent form of malarial fever, with varying intervals between the par- 
oxysms. The characteristic form of this Plasmodium is the pigmented 
crescent. 

The Plasmodia of malaria enter the red blood-cells and live at their 
expense. The resulting anemia is due to the destruction of the large 
number of erythrocytes, the parasites deriving their pigment from the 
hemoglobin of the red corpuscles upon which they have fed. 

Transmission. — Malaria is transmitted from one human subject to 
another by the bite of the Anopheles, a species of mosquito. 

The fully developed parasites are most readily found in the blood 
an hour or two before the onset of the paroxysm. 

Craig states that in malarial localities children suffer much more 
severely from the disease than do adults, and that malaria is often 
latent in young subjects. The disease may occur in very young in- 
fants, but is always of postnatal origin. Thayer and others have 
shown conclusively that malarial parasites are not transmitted through 
the placental circulation. 

Malarial fever contracted in New York city is of very unusual oc- 
currence. Patients coming under my observation have, with few ex- 
ceptions, resided elsewhere, or contracted the disease while in the 
country during the summer. Every autumn a few cases of such origin 
are treated. They are usually of the tertian type. 

Pathology. — The most marked pathologic changes in malaria are 
found in the blood, since the plasmodia feed upon the red blood-cor- 
puscles. As a result, there is a marked reduction in the number of 
erythrocytes and in the amount of hemoglobin; there is, further, the 
production of a large amount of black and brownish yellow pigment. 
The leukocytes are also decreased in number, while there is a relative 
increase of large mononuclear cells. 

At autopsy upon patients dying of pernicious malaria characteristic 
lesions are found in the brain, spleen, and liver. The brain usually 
shows congestion and capillary hemorrhages due to blocking and rup- 
ture of the capillaries by plasmodia and pigment. There may be pig- 
mentation of the gray matter. The capillaries contain infected blood- 
corpuscles, free plasmodia, free pigment, macrophages often large 
enough to block the vessel, and pigmented leukocytes. The nerve- 
cells show marked degenerative changes. 

The liver is enlarged, fatty, pigmented, and congested. In the 
capillaries malarial plasmodia and pigment are seen within macro- 
phages, but only very few plasmodia are found within red blood-cells. 



668 THE PRACTICE OF PEDIATRICS 

The liver-cells are degenerated, and sometimes pressed out of existence 
by the distended capillaries. Areas of focal necrosis occur with an 
increase in the connective tissue around them. 

The spleen is enlarged and pigmented, and the pulp is soft and dark 
colored. The venous sinuses are congested, and there are many Plas- 
modia free in red blood-cells, in macrophages, and in smaller cells ; there 
is also free pigment. The splenic connective tissue is increased only 
in those cases in which repeated attacks of malaria have occurred. 

The other viscera do not show specific lesions of any kind. All the 
capillaries contain malarial plasmodia, and there is present more or 
less pigmentation. The epithelial cells of the kidneys and adrenals 
are usually degenerated as the result of the toxemia. The heart may 
be flabby and anemic. The lungs may show congestion, edema, or 
bronchopneumonia. 

Symptoms. — The symptoms vary somewhat with the age of the 
patient; thus an infant, instead of giving evidence of a chill, which 
signals the onset in older children, beconies cold, blue, and pinched in 
appearance. Vomiting or convulsions may take the place of a chill. 
Whatever the nature of the immediate onset, fever follows, which rarely 
continues longer than five or six hours. This stage may not be followed 
by sweating. About the same time, on the following day or the day 
after, the same phenomenon is repeated. The patient is very com- 
fortable between the seizures. 

Physical Examination. — Physical examination of the patient will 
reveal enlargement of the spleen, a condition almost invariably present 
in malaria in children. In neglected cases signs of malnutrition rapidly 
develop regardless of the age. They differ in no way, however, from 
those dependent upon febrile conditions due to other causes. 

Relapse. — When relapse occurs, it means one of two conditions — 
reinfection, or a case not cured. A relapse after weeks or months is 
not uncommon. In my observation, in cases which have been treated 
with quinin for only a week or two, until the active symptoms subside, 
after a certain time, another sharp attack results. The manifestations 
are occasionally milder. There is, perhaps, a low periodic temperature 
without chill, the temperature not reaching a point above 101° or 102° 
F. I have time and again had this feature of the disease brought to 
my attention. These cases represent what is sometimes designated 
as chronic malarial poisoning or persistent malarial infection. In non- 
malarial sections reinfection is an improbability. 

Diagnosis. — The positive diagnosis of malaria depends upon finding 
the malarial organism in the blood, provided, of course, that quinin 
has not been previously given. 

The next best means of diagnosis consists in the use, in suspicious 
cases, of adequate doses of an assimilable preparation of quinin. An 
immediate control of the temperature is strong presumptive evidence 
that malaria has existed. When full doses of quinin do not control 
the temperature, this fact usually means that malaria does not exist 
and that there are other causes for the illness. 



MALARIA 669 

Differential Diagnosis. — There are probably very few diseases with 
fever which have not many times beeii confused with malaria. In fact, 
the erroneous diagnosis of malaria has probably been made more often 
than all other diagnostic errors combined. 

There are many conditions in which there may be a remittent tem- 
perature period, and which may be looked upon as malaria; an enu- 
meration is unnecessary. Probably elevation of temperature due to oc- 
cult pus is responsible for more diagnoses of malaria than is, any other 
agency. Influenza, typhoid fever, tuberculosis, and periodic fever 
due to fatigue often have the diagnosis of malaria attached to the ail- 
ment. With blood examinations and the various newer diagnostic 
methods there is no occasion for errors in differentiation. 

Prophylaxis. — The prophylaxis consists entirely in keeping the 
child free from the anopheles mosquito. 

Treatment. — When it is demonstrated that malaria exists, quinin 
should be given in what may be considered large doses, if we are to use 
the adult for comparison. Children tolerate quinin well; in fact, to be 
effective, a much larger amount comparatively is required than in 
adults. In giving quinin to young children care must be used in its 
administration lest it excite vomiting. For this reason it should be 
given after meals in solution or in capsule. The best menstruum is a 
preparation of yerba santa, known as Yerberzine.* A child under 
eighteen months of age will require from 8 to 12 grains of quinin daily. 
Two to three grains of the bisulphate should be given at a dose, not 
more than four doses being given in twenty-four hours. 

When I was resident physician at the New York Infant Asylum, 
then located in southern Westchester County, New York, there was a 
great deal of malaria among the women and children inmates. In that 
institution I repeatedly gave infants under four months of age 8 grains 
in twenty-four hours. In some cases at this age a larger quantity — 
10 to 12 grains — will be required. Quinin chocolate tablets are some- 
times used in giving the drug to children. In using these tablets it 
must be remembered that the contained quinin is in the form of the 
tannate, and that one grain of the tannate represents about J^ grain of 
the sulphate. If sufficient quinin to be of value is given in this form, 
the large amount of chocolate in the tablet will surely upset the diges- 
tion. To children under one year of age with whom Yerberzine may 
disagree because of the sugar which it contains, the bisulphate may be 
given in solution in distilled water, followed by a teaspoonful of orange- 
juice. For older children, — from two to six years of age, — from 15 to 
30 grains daily will be necessary to control the disease. To these, as 
to the younger children it should be given in Yerberzine unless the 
child can be taught to take a capsule, when the quinin may be given 
in 3-grain doses at two-hour intervals until the prescribed daily amount 
has been taken. 

The giving of a large dose of quinin a few hours preceding the ex- 

* Made by Lilly and Co. 



670 THE PRACTICE OF PEDIATRICS 

pected chill does not answer well in children, as a large amount given 
at one time may frequently cause vomiting. 

Special Methods of Administration. — The use of quinin by inunction 
or by the rectum has not been satisfactory. Its use by these methods 
was attempted at the Infant Asylum in a great many cases where 
difficulty was experienced in the stomach-administration. 

With but one patient, aged two years, have I been obliged to resort 
to hypodermic medication. The child showed the tertian parasite, 
and the disease resisted the internal use of quinin in large doses, but 
responded promptly to the muriate of quinin given hypodermatically, 
7 grains being used at one injection. There was no abscess at the site 
of the injection, and the child was permanently cured. To be sure, 
the administration of quinin was continued by the mouth, but the 
dosage of 16 grains daily was now apparently effective, where pre- 
viously it had made no impression. 

Recurrence. — The use of quinin in malaria should not be stopped 
abruptly upon a cessation of the fever. It is my custom to give the 
drug in full doses for one week after the temperature fails to rise unless 
there is a subnormal temperature, in which event the drug is reduced 
one-half or temporarily discontinued. It is a difficult matter to deter- 
mine when a case of malaria is cured. Time and again I have sup- 
posed that a patient was well when a recurrence of the paroxysm took 
place weeks afterward. How often this was due to reinfection, and 
how often to the old infection which had not been entirely eradicated, 
it is difficult to say. I am inclined to the belief, however, that in 
many instances the Plasmodium had remained inactive in the spleen 
in spite of the return of that organ to nearly its normal size, for the 
reason that the recurrence of symptoms sometimes took place coinci- 
dent with some other illness with fever, such as tonsillitis or acute 
indigestion. My experience with recurrences of the disease has been 
such that, after an attack of malaria, I now direct that the child be 
given quinin for one week out of each month, for an indefinite time — 
at least for a year following the original attack. 

Illustrative Case. — In a comparatively recent case, a girl five years of age had 
repeated attacks for two years before coming under my care. The mother was 
instructed to give the child 12 grains of the bisulphate daily for seven days out 
of each month. This, without a change of residence, was suflBcient to prevent a 
recurrence during the fifteen months which followed. 

INFLUENZA 

Influenza is an acute infectious disease due to the Bacillus influenzae, 
first described by Pfeiffer as a result of his studies during the great 
pandemic of 1889-90. 

Bacteriologic Etiology. — It is a slender, non-motile rod, which stains 
deeply at the poles, does not retain the Gram's stain, and is very pleo- 
morphic. Its one unvarying characteristic is its utter inability to grow 
in media which do not contain hemoglobin. On agar mixed with 
human, pigeon's, or rabbit's blood, its cultivation is an easy matter. 



INFLUENZA 



671 



The colonies are small and dew-drop like, they do not coalesce, and 
they do not cause hemolysis in the surrounding medium. 

Mode of Entrance. — It is the rule for the influenza bacillus to enter 
the human body through the upper respiratory tract, whence it may 
travel down into the lung, causing bronchitis or bronchopneumonia. 
In comparatively few cases it is the cause of otitis media. General 
blood invasion with Bacillus influenzae is a rare condition, which is 
usually, but not invariably, accompanied by purulent inflammation 
of one or more serous membranes — meningitis, pleuritis, pericarditis, 
peritonitis, arthritis. 

Source of Infection. — The source of infection is contact with an 
acute case of influenza or with a carrier. In either instance the secre- 
tions from the nose or bronchi contain the bacilli in a moist state. The 
organisms do not resist drying long enough to make clothes or Hnen a 
probable source of contagion, but they do remain viable for months in 



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the bronchial secretion of cases of influenzal bronchitis, with or without 
bronchiectasis, and they have been found there six months after an 
attack of pertussis (Davis). 

The work at the New York Babies' Hospital (Wollstein) has shown 
that the influenza bacillus is present in the bronchial secretion of young 
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prone to infection with the influenza bacillus. It may, in such cases, 
by causing a terminal bronchopneumonia, be the actual cause of death. 

Age. — All ages are susceptible, particularly infants under one year. 

Pathology. — Influenza supplies no distinct lesion of its own. In 
the respiratory tract, where the bacillus is most active, there may be 
only the changes characteristic of bronchitis or there may be a broncho- 
pneumonia due to B. influenzae in pure culture. The bacillus is most 
fertile in its power of producing lesions in various organs, but these 
lesions in no sense differ from those produced by other forms of 
infection. 



672 



THE PRACTICE OF PEDIATRICS 



Incubation. — The period of incubation may be very short. It is 
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Fig. 91. — Prolonged influenzal infection. — {Continued.) 

to 103°F. or higher. The throat is reddened, and there may be a few 
coarse rales in the chest. The symptoms subside, and the child is well 
in five or six days. After the second year children complain of head- 
ache and muscle soreness; there is also a failure of appetite. This rep- 
resents a mild attack of the type seen in a great majority of the cases. 



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Fig. 92. — Prolonged influenzal infection; — {Continued.) 

Severe cases show the above signs, with the exception that there are 
higher fever and much greater prostration. Convulsions are unusual, 
but headache and extreme restlessness are often present. 

Cough. — The cough in the severe type is often most troublesome. 



INFLUENZA 



673 



The most severe coughs do not occur, necessarily, when bronchitis is 
a compHcation. The hard, persistent cough, without expectoration, 
without rales, or with but a few rales in the chest, may be said to 
typify the cough of influenza. Every year I see patient after patient 
who has the nagging tracheal cough not only during the attack, but 



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Fig. 93. — Prolonged influenzal infection. — {Continued.) 

sometimes for weeks afterward, without a sign in the throat other than 
perhaps unusual redness, and without a chest sign. The influenza 
bacillus seems to have a special tendency for localization in the trachea. 
G astro-intestinal Manifestations. — Occasionally grip is ushered in 
with pronounced gastric disturbance. There will be nausea and vomit- 



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Fig. 94. — Prolonged influenzal infection. — (Continued.) 



ing, no food being retained for twenty-four to forty-eight hours. Pro- 
nounced intestinal disturbance is by no means an unusual evidence of 
infection with the influenza bacillus; there may be diarrhea without 
any evidence of involvement of the intestinal structure, or there may 
be colitis with tenesmus and mucus and blood in the stools. In not a 
43 



674 



THE PRACTICE OF PEDIATRICS 



few cases the so-called complications are the only manifestations of the 
infection. This has led writers to describe a ''grip colitis," a ''grip 
gastritis," etc. 

The Temperature. — The temperature characteristics of influenza 
are peculiar. There is a tendency to wide, irregular variations from 
normal to 105° or 106°F. and back again. I have repeatedly known 
the temperature to range from 100° to 103° or 104°F. for six or eight 
weeks (see charts), without other lesion than that of a catarrhal bron- 
chitis. A peculiar feature of these uncomplicated grip cases is the 
height to which the temperature will rise daily and its long continua- 
tion for many days with insignificant signs of illness and absence of 
effects on the patient. 

Fatal Cases. — Fatalities from uncomplicated influenza are unusual. 



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Fig. 95. — Prolonged influenzal infection. — {Concluded.) 



Illustrative Cases. — Two cases of grip in infants in which the diagnosis was made 
by exclusion and verified by autopsy occurred at the County Branch of the New 
York Infant Asylum during the winter of 1888 and 1889, which, it will be remem- 
bered, was the time when grip first visited this country in epidemic form. These 
healthy, breast-fed babies were taken with the disease, together with about 40 
other inmates, mothers and children, in one of the large wards. The infants in 
question, aged three and four months respectively, were stricken suddenly with 
high fever and marked prostration. They quickly went into a condition of col- 
lapse, and both died in less than thirty-six hours from, the onset. The autopsy 
failed to show any pathologic change other than a slight hypostatic congestion of 
the lungs. 

Complications. — The influenza bacillus alone may produce otitis, 
meningitis, pericarditis, periarthritis, peritonitis, and nephritis of the 
hemorrhagic type. The chief danger attending its invasion of the 
body is its ability to prepare a field for the development of other patho- 
genic organisms. 

The most frequent complication of grip is bronchitis, and the most 
fatal complication is bronchopneumonia. 

Suppurative otitis is not an infrequent complication; perhaps it 
would be better to class it as a grip sequela. Among 72 cases of acute 
suppurative otitis referred to elsewhere, 59, or 81.9 per cent., occurred 
with or followed immediately upon an attack of grip. Patients who^ 



INFLUENZA 675 

after an attack of grip, run a temperature without any apparent cause, 
should be examined by a skilled otologist. 

Adenitis is a complication in many cases. I have seen cases of 
endocarditis associated with grip. 

The Kidneys. — In nearly all cases of severe infection a slight amount 
of albumin will be present in the urine during the entire period, and 
occasionally, in a few cases, hyaline and granular casts will be found. 
The irritation is only of temporary duration, and subsides after a few 
days. 

In a very large experience with all types of influenza I have never 
known the association of acute parenchymatous nephritis with grip, 
such as occurs with scarlet fever or the other exanthemata. 

Every year I see about six cases of acute hemorrhagic nephritis 
complicating influenza. These cases are peculiar in that there is a 
large amount of blood with few hyaline and epithelial casts. There is 
little or no suppression of the urine and no edema or sign of nephritis ex- 
cepting the urinary findings. I have never lost a case although micro- 
scopic blood and casts have been present in the urine for several weeks. 

Duration. — The duration may be two or three days, or it may be 
two or three months. One attack of the disease confers no immunity. 
The long-continued cases are those of reinfection and recrudescence. 

Prognosis. — The prognosis of influenza is favorable in the absence 
of complications. With complications the outcome depends upon the 
nature of the associated disease. Further, it is to be remembered that, 
as a complication of bronchitis and pneumonia, influenza supplies a 
decided additional danger. 

Diagnosis. — From simple internal colds a differentiation may be 
impossible without a bacteriologic examination. In influenza there is 
a tendency to chronicity and reinfection, with widely fluctuating tem- 
perature, irregular as to rise and fall. It seems most difficult for the 
patient completely to recover. Meningitis, malaria, and typhoid fever 
may be confused with grip, but may be readily differentiated by the 
well-known diagnostic methods. In any case of influenza the ears 
should be subjected to daily examination, as otitis may cause an eleva- 
tion of temperature identical with that of a protracted case of uncom- 
plicated influenza. 

Sequelae. — After even a moderately severe attack of grip the 
patient is left in a condition that is peculiar to this disease and none 
other. He is habitually tired, easily fatigued upon slight exertion, 
shows but little tendency to take up active play, and, if older, finds 
school work very diflacult. In a large proportion of cases there will be a 
shght elevation of temperature nearly every day — rarely higher than 
101 °F. A feature of these temperature cases is that the attack may 
not have been at all severe. Every winter and spring I am repeatedly 
consulted about the tendency to elevation of temperature after grip. 
In some cases the temperature will continue for months. It will be 
normal — 98.5° to 99°F. — in the morning, perhaps 100°F. or thereabouts 
at noon, and 101°, or 101 °F. and a fraction at night. It rarely reaches 



676 THE PRACTICE OF PEDIATRICS 

102°F. The persistent temperature cases are not due to disease proc- 
esses or to the presence of the influenza bacillus in the bronchial 
tract, as has been claimed, but to constitutional weakness and fatigue. 
In some way, through the action of the toxins of the disease, the heat- 
regulating center becomes involved, and through activities which 
ordinarily would not produce any effect an influence is exerted causing 
an elevation of the temperature. That a portion of this deduction is 
correct may be readily proved by keeping these patients quiet in bed 
for three days, and taking their temperature at the usual intervals, 
morning, noon, and night (6 p. m.). It will be found, if they are kept 
quiet and the bowels active, that the temperature will remain within 
the normal limits — not above 99°F. I have demonstrated this in a 
great many cases. If it continues uninfluenced, there is a discernible 
cause which should be discovered. After grip, because of the child's 
low physical state, he is often urged to take more food than he can 
assimilate, and there may be a mild degree of intestinal indigestion, 
producing sufficient toxic effects to cause the temperature, yet unob- 
served because of the absence of active symptoms. I have known the 
free use of milk and cream to produce a slight persistent elevation of 
the temperature after grip. Tuberculosis of the bronchial glands may 
produce a similar but not persistent temperature range. 

Quarantine. — Individuals with influenza should be quarantined 
(p. 649) from other members of the household. Older members of 
the household are often the bacillus carriers and infect the younger 
members. 

One attack of grip confers no immunity upon the patient; in fact, 
patients apparently reinfect themselves. For this reason I always 
advise that two rooms be used, when possible, one for the day and one 
for the night, the room not occupied during the day being aired for sev- 
eral hours with all the windows open. After recovery, the sick-rooms 
should be thoroughly aired, cleaned, and fumigated with sulphur, for- 
maldehyd, or chlorin gas. 

Treatment. — The individual treatment is symptomatic. The 
rhinitis and bronchitis are treated as if the condition were not grip. 

The management of an otitis, pneumonia, bronchitis, or colitis as- 
sociated with or following an attack of influenza, differs in no way, so 
far as the immediate treatment of the complication is concerned, from 
that which' would be advised if the case were independent of the influ- 
enza bacillus. The case, as a whole, however, will require closer watch- 
ing, and on account of the greater prostration, better feeding and freer 
stimulation. 

The hard, dry, teasing, tracheal cough associated with and following 
many cases of influenza, is sufficiently troublesome to require special 
mention. In this condition codein should be used in sufficient dosage 
partially to control the cough. The cough is difficult to relieve for the 
reason that the mucous membrane of the trachea is deeply congested. 
The infection, aided by the persistent cough, keeps up and adds to the 
congestion; and the irritation thus produced again tends to a persis- 



SYPHILIS 677 

tence of the cough. This is a condition where opium is not only justi- 
fiable, but absolutely necessary, in order that sufficient rest of the parts 
may be secured to allow resolution and control of the infection. 

Fapor. —Charging the air with vapor, producing an artificial hu- 
midity, greatly lessens the irritating effects on the mucous mem- 
brane of the ordinarily dry air of the hving room, and reheves the 
cough. 

External Treatment. — A preparation of mustard, — one part flour to 
two parts mustard, — suitably mixed and applied to the chest for five 
to fifteen minutes at bed-time, will often insure a better night than 
would result were the application not made. 

Change of Climate. — When possible, patients who show pronounced 
systemic depression and who fail to regain their usual physical vigor 
should have the benefit of a change of climate. A change of a few 
weeks will ordinarily completely restore the patient to his normal 
health. When at home, or elsewhere, convalescent grip patients who 
show slow response to treatment should have their activities carefully 
advised; they should not be allowed to arise before 10 in the morning, 
should have a midday rest of two hours, and should retire between 6 
and 7 o'clock. 

Drugs. — Small doses of quinin, one to two grains at two- or three- 
hour intervals, have given better results in hastening a return to health 
than any other form of medication. If there are malnutrition and 
anemia, the measures laid down under the respective headings may be 
applicable to these patients. 

SYPHILIS 

Syphilis is an infectious, communicable disease seen with great fre- 
quency in early life in all large centers of population. 

In 1905 Schaudinn and Hoffmann discovered a spirochete in syphi- 
litic lesions. From its faint staining reaction they named the organ- 
ism Spirochaeta pallida, and later Treponema pallidum. It is present 
in syphilitic lesions on the skin and mucous membrane, and has been 
found in the blood, in the internal organs, in the lymph-nodes, in 
spermatozoa, in ova, and in cerebrospinal fluid of syphilitic patients. 
The tissues and organs of still-born syphilitic infants contain the 
spirochete, and in congenital ly syphilitic children the organism is 
readily demonstrable in the mucous patches in the mouth, in the fis- 
sures about the mouth and anus, and in the skin lesions. The older 
the lesion, the less numerous are the spirochetes. 

Noguchi was the first investigator who succeeded in obtaining pure 
cultures of Treponema pallidum, and by inoculating such pure stains 
into rabbits he has produced syphilis in these animals. There can no 
longer be any doubt of the etiologic relationship between Treponema 
pallidum and syphilis. The spirochete is mobile, varying in length 
and thickness, its average transverse diameter being 0.2 to 0.3 micron. 
It is best seen in the fresh state, with the dark field illumination. A 
rough but fairly reliable method of demonstrating the spirochete is to 



678 THE PRACTICE OF PEDIATRICS 

mix the material to be examined on a slide with a drop of India ink. 
By means of a piece of cigarette paper the mixture is easily spread 
evenly along the slide. Examination with the immersion lens shows 
the unstained spirochetes on a black background. 

The disease in children is usually due to direct inheritance, although 
acquired cases are occasionally encountered. We have accordingly 
to consider both the hereditary and the acquired types. (See p. 685.) 

For convenience of description hereditary cases are discussed under 
two headings: Acute hereditary or congenital and later or tardy syphilis. 

Acute Hereditary or Congenital Syphilis 

The severity of the infection in the offspring bears a distinct rela- 
tionship to the severity and recentness of the infection in the parent or 
parents. As in all infections, the disease may be most severe, or mild 
to such a degree that its existence is not recognized. A recent infec- 
tion in either parent, or in both, produces the most active manifesta- 
tions, many times sufficient to destroy the life of the fetus or even to 
preclude pregnancy. Death of the fetus, showing marked syphilis, 
any time before the ninth month indicates a comparatively recent 
infection in the parents. It is the parents in whom the disease is of 
long duration or who have undergone active treatment who are respon- 
sible for the tardy hereditary form. 

Symptoms. — The symptoms, which are most variable, depend 
upon the age of the patient and the severity of the infection. 

Thus the child may be born dead at term. I have repeatedly seen 
these infants almost denuded of skin and showing bone and extensive 
visceral lesions. 

In other instances the child is born at term, alive, but shows syphi- 
litic pemphigus and other lesions, and lives but a few hours. Other 
infants are born apparently normal and show signs of the disease be- 
fore the sixth week. Symptoms are very apt to appear between the 
second and fourth weeks. Seventy-five per cent, of my cases have 
shown diagnostic signs before the fourth month. Some cases do not 
show signs until a later period — the sixth, seventh, or eighth month. 
Such cases, however, are unusual. The great majority show some 
active evidence of the disease before the sixth month. The first 
manifestation in congenital syphilis may appear at any time up to the 
thirtieth year (Fournier). 

In infants apparently normal at birth and developing the signs early 
the symptoms are as follows: 

(1) Restlessness. 

(2) Rhinitis; hoarse voice. 

(3) Enlarged liver and spleen. 

(4) Rash; condylomata; mucous patches. 

(5) Enlargement of epitrochlear glands. 

(6) Deformities of the nails. 

(7) Defective growth and malnutrition. 



SYPHILIS 



679 



Restlessness is the earliest symptom of syphilis. The child sleeps 
poorly and is uncomfortable. This symptom is many times not appre- 
ciated by the physician and usually passes unrecognized by the parents. 
The restlessness is usually attributed to causes other than syphiHs. 




Fig. 96. — Rash in congenital syphilis. 

Rhinitis is a very early symptom, and one that is seldom absent. 
It is characterized particularly by its persistence and the profuseness 
of the discharge; in other respects it may not vary from an ordinary 
rhinitis. 




Pig. 97. — Condylomata. 

In a considerable proportion of these cases there is a moderate de- 
gree of laryngitis with hoarseness. I have seen cases in which this sign 
was the earliest and most prominent symptom. 



680 



THE PRACTICE OF PEDIATRICS 



Liver and Spleen, — An enlargement of the liver and spleen is an 
early sign in most cases. The spleen will be palpable below the rib for 
3/^ to 2 inches. The liver also shows enlargement, often extending 2 

to 3 inches below the free 
border of the rib. 

The Rash. — The rash 
may appear very early or 
may be delayed for a week 
or longer after the rhinitis. 
The rash is fairly charac- 
teristic. It appears in dis- 
crete, brownish -colored 
macules (Fig. 96), rounded* 
and with a tendency to a 
very fine desquamation in 
the center. The skin be- 
tween the macules may 
remain normal. The ma- 
cules may occur in groups 
and become so extensive 
as to coalesce and involve 
a large part of the skin sur- 
face of the patient (Fig. 98) . 
The moist parts about 
the buttocks, legs, and over the abdomen are usually involved first 
and most extensively. There is no order, however, as to the appear- 
ance of the rash, the face and the arms may be first affected, or the 
rash may be generally distributed over the entire skin surface. When 




Fig. 98. — Extensive syphilitic rash. 




Fig. 99. — Fissures and mucous patches. 

the rash fades, the skin becomes smooth, but there is left a copper- 
colored stain which is as characteristic of the disease as the rash. 
When the eruption occurs about the anus or the moist parts, as in 



SYPHILIS 



681 



flexures and skin folds, the eruption sloughs and condylomata are 
formed (Fig. 97). 

In many cases, particularly in very young infants, a diffuse thicken- 
ing of the skin of the soles of the feet and palms of the hands occurs 
with profuse desquamation (Fig. 100), leaving the skin of a glossy, 
shining appearance. How long the skin eruption would continue un- 
treated if the patient survived is difficult to determine. Under suit- 
able medication the eruption largely disappears in two to four weeks, 
leaving the copper-colored disfigurations, which in turn fade, but 
require a much longer time (Fig, 98) . 

Fissures at the angles of the mouth and on the lip and mucous 
patches (Fig. 99) are really a part of the skin manifestations — they are 
characteristic in the sense that they occur only in syphilis. A mucous 
patch represents the site of papule or macule on a moist surface. Such 




Fig. 100. — Desquamation. Soles of feet. Congenital syphilis. 



lesions are usually found on the mucous membrane of the mouth. 
Other possible sites are the anus and the female genitals. 

Acute epiphysitis occurs in young infants, but in this country it is 
an unusual manifestation of syphilis. There is swelling of the epiphy- 
seal cartilages and there may be separation of the epiphysis. The parts 
are very painful, giving rise to' the term ''syphilitic pseudoparalysis." 

The Nails. — The nails are dwarfed, dry, and break readily. There 
may be exfoliation of the nail, but this is unusual in infants. A char- 
acteristic deformity is the bird-claw nail, in which the nail is much 
contracted, showing an arching of the dorsum of the nail with thicken- 
ing, and a downward curve at the free end, over the tip of the finger 
or toe, producing a typical claw appearance. This is a symptom of 
much diagnostic value. 

Hemorrhage. — Hemorrhages in congenital syphilis are rare. They 
may occur from any mucous surface. In a large number of cases of 
congenital syphilis seen in this country and on the continent there were 



682 THE PRACTICE OF PEDIATRICS 

but two in which hemorrhage was a symptom. In both these cases, 
strange to say, there was quite severe hemorrhage from the vagina. 

Treatment. — Mercurial Treatment. — Until recently the only means 
of treating congenital syphilis in infants was by the use of mercury, 
locally, as by inunctions, or by internal administration. The use of 
mercurial ointment by inunction is a satisfactory method in hospitals 
and in children's institutions, where a nurse can make. the necessary 
applications; in private practice, however, it is objectionable because 
of the inunction itself, which may cause comment, and because of the 
staining of the skin. In fact, this treatment cannot well be carried on 
without other members of the family becoming acquainted with the 
nature of the illness. Definite rules for management, as regards kissing 
and the care of feeding utensils, should be given, so that the other mem- 
bers of the family may be protected and the real condition remain 
unknown. Among the poorer class, and in outpatient work, I have 
found the inunction method unsatisfactory, for the additional reason 
that its use is not continued sufficiently, and it is very apt to be indif- 
ferently done. It is often postponed and forgotten. As the disease 
permits of no temporizing, it is for the interest of the patient that the 
most effective jneans possible for its control be brought into use at the 
earliest possible moment; this is by the internal administration of 
mercury. 

If the inunction is employed, the mercurial ointment, U. S. P., 
should be used, 10 grains being rubbed into the skin daily. The rub- 
bing should be continued about ten minutes, as this time will be re- 
quired for the ointment to be thoroughly absorbed. 

Bichlorid Hypodermically Administered. — Veeder of St. Louis in a 
private communication states that the bichlorid of mercury adminis- 
tered hypodermically is quite comparable in rapidity of results to 
salvarsan. A 1 per cent, solution of bichlorid is used. In runabouts 
and older children Veeder injects from 10 to 20 minims every other day 
for six injections, then rests for a week and repeats the course. The 
injection is given into the muscles of the buttocks. In young infants 
the dosage is 3 minims. 

Frequent examination of the urine is necessary during this treat- 
ment because of the possible development of nephritis. 

The Internal Use of Mercury. — The use of mercury internally gives 
the best results among all classes. It is my observation, after the 
treatment of several hundred of these cases, that the bichlorid of mer- 
cury in small, frequently repeated doses is the best form of medication. 
It is given in tablet form. Its use may have to be continued for a long 
time, and, as people are fond of giving drugs, we cater to the weak side 
of human nature, and thus do the greatest good to our patient. 

The Dosage and Method of Administration. — For all infants under 
one year of age the scheme of medication is the same, and this covers 
the great majority of our cases. Usually the patient is seen before the 
third month. I order the tablet triturate of bichlorid of mercury, J-200 
grain. The mother is instructed to give two tablets daily, morning 



« 



SYPHILIS 683 

and night, after feeding. She is told to give on alternate days an 
additional tablet after feeding, until five are given daily, or until the 
mercury produces loose green stools. It is comparatively rare that an 
infant of the tenderest age cannot take 3^o grain daily without incon- 
venience. If green stools of a watery character result, the increase is 
temporarily withheld. It is very rare that the above amount will not 
ultimately be taken without inconvenience. Further, the dosage of 
3^0 to 3^0 grain in twentj^-four hours, in the great majority of the cases, 
is all that is necessary to control the disease. If an improvement does 
not take place after a week's administration, in the absence of intestinal 
symptoms, the amount may be increased to J^o grain in twenty-four 
hours. 

If, after the administration four or five times daily of the bichlorid 
in the small doses of 3^^oo grain has been continued for several days, im- 
provement does not take place because of failure on the part of the 
child to absorb the drug, inunctions may be used in addition to the 
internal treatment. This has been necessary, however, in but few of 
my cases. 

Convalescence. — In a typical case the first sign that the child is im- 
proving will be the fading of the rash. It disappears gradually, leaving 
the characteristic staining of the skin, which also clears up in a few 
weeks. Coincident with the fading of the rash, the coryza becomes less 
pronounced and the hoarse voice becomes clearer. If there has been 
an enlargement of the liver and spleen, after a few weeks of treatment 
they will be noticed to have diminished in size. The child gains in 
weight, and if the case progresses satisfactorily, soon looks like a normal 
baby. This, however, is not always the happy outcome. Occasion- 
ally we have patients with the vital powers greatly depressed or with so 
intense an infection that treatment is of no avail, and they die in a few 
weeks from marasmus. In such cases and in all instances of very 
severe infection salvarsan should be given wdth mercury. The action 
of the salvarsan is very prompt and will check the progress of the 
disease much sooner than mercury, regardless of its method of 
administration. 

The enlargement of the epitrochlear glands is, in my experience, the 
last sign to disappear, and in many cases these glands, though reduced 
in size, always remain enlarged without any other persistent evidence 
of the disease. A patient is considered cured who fails to give a posi- 
tive reaction to repeated tests of the blood, according to the Wasser- 
mann method. 

Later Treatment. — What should be the further management of such 
a so-called ''cured" case? Are we justified in discharging the patient 
and allowing him to pass from our observation? My experience proves 
the contrary, nor can I state that congenital syphilis is ever cured. I 
have seen many patients, however, who were apparently cured, and who 
showed no signs whatsoever of the disease. Against my advice they 
have passed from observation for two, three, or four years, and then 
have reappeared for treatment, because of the presentation of some 



684 THE PRACTICE OF PEDIATRICS 

manifestation of a tertiary character — a so-called ''tardy hereditary 
syphiHs.'^ For this reason I beheve every so-called cured congenital 
case should be subjected to the Wassermann test every two years or 
oftener. 

The Arsenicals in the Treatment of Hereditary Syphilis. — In chil- 
dren, neosalvarsan is now used almost to the exclusion of salvarsan. 
The technic is much less complicated, leakage into the tissues much 
less serious and the untoward by-effects ascribed to salvarsan are never 
seen. However, the effect of the neosalvarsan is not so spectacular 
nor so lasting as that of salvarsan. 

The greatest value of the arsenicals is in the very severe congenital 
case. Repeatedly I have seen these infants die before the effects of 
mercury could be manifested. The arsenicals act much more rapidly 
than mercury. In fact, the results of salvarsan treatment on the very 
severe congenital syphilitic borders on the miraculous. 

The chief value of salvarsan in pediatric work is in this type of 
case: for permanent, beneficial effects we are still dependent upon 
mercury and the iodids. 

Dosage. — For babies under six months, the average dose of neo- 
salvarsan is 0.075 gm. to 0.2 gm. and for older children 0.2 gm. to 
0.4 gm. Salvarsan is used in doses one-half as large. The consensus 
of opinion now seems to be that the arsenical should be given at weekly 
intervals until the gross lesions have cleared up. This is always 
followed by the use of mercury. The arsenicals do not effect a cure 
alone. 

Technic. — The technic advised by Holt and Brown* and carried 
out at the Babies' Hospital is as follows: 

The patient is tightly wrapped in a sheet to secure the hands to the 
sides in order to prevent struggling. The child is then placed on the 
table with the head hyperextended and turned to whatever side is 
desired and held in this position by an assistant. By this method, 
introduction of the needle of a glass luer syringe is readily effected 
into either of the auricular veins during a paroxysm of crying. The 
scalp veins are chosen because of the fact that they lie more superfi- 
cially and are more firmly bound by connective tissue, thus facilitating 
the introduction of the needle. The external jugular veins may be 
used in a similar manner. 

The mode of treatment by the injection of salvarsan into the supe- 
rior longitudinal sinus is a safe and easy method of intravenous injec- 
tion in infants. In the average new-born infant, the sinus at the pos- 
terior angle of the fontanelle is about one-quarter of an inch wide; in 
the sagittal suture one and a half inches behind the fontanelle, it is 
about five-sixteenths of an inch. The latter position is the better 
choice, as long as the suture remains open. A 20 c.c. glass luer syringe 
with an 18 or 20 gage needle with a sharp bevel (about 45 degrees) is 
used. The needle has a furrow filed in it about five-sixteenths of an 

* Amer. Journal Diseases of Children, Sept., 1913. 



SYPHILIS 685 

inch from the tip. A silk thread is tied in the furrow and then wound 
a few times about the needle above the groove and tied again. This 
acts as a guard to prevent the needle sinking too deeply into the sinus. 
The infant is held firmly on its back with the head slightly flexed. 
The needle is passed into the sinus from before backward with the 
bevel of the needle parallel with the skin, so that the opening in the 
needle is patent as soon as it enters the sinus. If the infant be crying 
the blood is usually forced up into the syringe if the piston be not held 
too firmly; otherwise the blood is drawn into the syringe to prove that 
the needle is within the sinus before the salvarsan is injected. Autopsy 
findings in cases in which the needle has passed through the sinus 
revealed no evidence of injury to the sinus or the presence of blood 
about the sinus. 

Diarsenol and arsenobenzol are excellent substitutes for neosal- 
varsan but offer the same dangers as salvarsan. These drugs, because 
of patent rights, cannot be made after the war in Europe. The dosage 
is the same as neosalvarsan. 



Acquired Syphh-is 

Acquired syphilis in children, in my observation, is a comparatively 
rare occurrence. The mouth is the most frequent site for the primary 
lesion, the genitals being rarely involved. Infection may be conveyed 
by direct contact, as in kissing or by sexual contact. The virus may 
be conveyed by intermediaries, such as toys, nipples, and feeding 
utensils. 

The recital of statistics and special modes of infection adds nothing 
to our knowledge of the subject. It is necessary to remember that a 
localized lesion, shghtly sloughing over its surface, indurated and 
sharply defined, may be in a child the initial lesion of syphilis. 

The treatment is the same as that of the hereditary form. 

Tardy Hereditary Syphilis 

In this form of syphihs the chief or only manifestation of the disease 
occurs at a later period of life. Fournier states that the first signs of 
the disease may appear as late as the thirtieth year. That the case in 
which positive signs are not observed until after the third year did not 
show unrecognized signs early in fife is an open question. Judging 
from my own patients, and what could be learned about their early fife 
from intelligent mothers or attendants, I am convinced that an indi- 
vidual may show signs of syphilis at varying periods after infancy with- 
out early signs of the disease. Several years ago I reported six cases 
of tardy malnutrition of syphilitic origin in which there had been no 
early signs of the disease. Since that time I have seen several other 
cases of a similar nature. 

The great majority of my patients with tardy hereditary syphilis 



686 THE PRACTICE OF PEDIATRICS 

however, are those who were treated in outpatient cUnics or elsewhere 
and who discontinued treatment when the active symptoms were re- 
Heved. I have had such experience with my own outpatients and 
have treated similar cases from other outdoor services. Many mothers 
cannot be made to bring their children for treatment and observation 
when they are apparently well. 

Pathology. — 1. Eye. — The eye changes are those of an interstitial 
keratitis, gummatous involvement of the iris, and the so-called deep 
inflammations of the eye, chorioretinitis and optic neuritis. 

2. Ear. — Progressive deafness due to neuritis acustica (Meniere's 
disease) . 

3. Skin. — According to Fochsinger, the changes in the skin do not 
differ from the tertiary skin lesions of acquired syphilis. He described 
two forms, first, small nodules, and, second, large nodular late syphilids. 
The small nodules are due to a definite infiltration of the true skin, 
which presents a brownish appearance and may desquamate or become 
covered with a heavy crust. Beneath the crusts there is usually broken 
down granular tissue. The large nodular syphilid occurs in the form 
of large skin gummata and gummatous ulcers arising from the sub- 
cutaneous tissues. 

4. Mucous Membrane of the Respiratory Tract. — This structure may 
become invaded in a specific manner. It may be the seat of gumma- 
tous infiltrations or a rapidly progressive ulceration. Ulcerations of the 
pharynx and larynx are not rare. Such lesions are usually character- 
ized by definitely defined borders and thick indurated walls. In the 
nose there may be a diffuse osseous and periosteal affection of the entire 
nasal skeleton, or a gummatous change may represent the primary 
pathologic process, followed by ulceration with much pus and crust 
formation. On the contrary, there may occur an atrophic condition 
of the mucous membrane. Levin and Heller describe a smooth atro- 
phy of the base of the tongue characterized by absence of glandular 
tissue and thinness of the mucous membrane. Gummatous formation, 
as described above, may occur on the velum palati, palatine arches, 
and uvulae, with perforation. All the ulcerations which take place 
show a great tendency to scar formation, with corresponding contrac- 
tions and adhesions to their adjacent parts. 

5. Lymph-nodes. — A general hyperplasia of the lymphatic tissue of 
the pharynx and nasopharynx, including the tonsils, may take place, 
while in the lymph-nodes throughout the body, aside from general hy- 
perplasia, gummatous formation is not uncommon. Occasionally the 
glands may undergo ulceration. 

6. Vessels. — There may exist, according to Hochsinger, a gumma- 
tous aortitis, arteriosclerosis, and phlebosclerosis, while myocardial and 
endocardial changes have been observed. 

7. Viscera. — Liver affections deserve the first rank. There may 
exist large nodular gummata; the diffuse hypertrophic cirrhosis is most 
common. These changes are almost always associated with more or 
less splenic hypertrophy. The kidneys may be small and contracted; 



SYPHILIS 



687 



amyloid degeneration is rare. Gummatous formation in the lungs 
may occur, but it is very uncommon. 

8. Bones. — Late syphilitic changes occur in the osseous system 
either as a diffuse hyperplastic ostitis and periostitis, or as a gumma- 
tous process; lesions of both varieties, however, may occur at the same 
time in the one individual. ^ According to Lannelongue, a hyperplastic 
ostitis and periostitis may involve the whole skeleton. The long bones 
are chiefly affected. The same author considers that the so-called 
Paget's bone disease, which is a diffuse progressive periostitis leading 
to hyperostosis, is 
nothing more nor less 
than hereditary 
syphihs. 

The tibia is the 
bone most frequently 
involved. The disease 
here produces what is 
known as the '^ saber 
deformity." (See Fig 
101.) Following the 
hyperplastic stage is 
the real stage of hyper- 
ostosis, the deformity 
being due to the con- 
tinuous formation of 
new periosteal bone 
layers about the 
primary one. 

Among the less fre- 
quent bone changes in 
late hereditary syphilis 
is a raref 3dng periostitis 
leading to bone absorp- 
tion. This condition 
is seen on the surface 

of the cranial bones and causes the formation of rough areas (caries 
sicca) . 

Joint affections may occur in late hereditary syphilis in the form of 
a simple hydrops without capsular thickening or a hyperplastic syno- 
vitis. Again there may be a combination of hydrarthrosis, with 
swelling of the joint-ends of the hollow bones, and in rare instances a 
condition resembling white swelling. 

Symptoms. — This form of syphilis in the young may manifest itself 
in widely different ways. 

Errors in Nutrition (see p. 689). — A not infrequent manifestation 
is that of moderate malnutrition and stunted growth. The patient is 
habitually pale, undersized, and shows lack of resistance, and such 
evidences may be the only signs of the disease. 




Fig. 101. — Showing saber deformity of legs in 
tertiary congenital syphilis in a child nine years 
of age" (Dr. Sill). 



688 



THE PRACTICE OF PEDIATRICS 



The Bones. — Characteristic signs are to be found in the bones and 
teeth. The shafts of the long bones are involved in a periostitis. (See 
Fig. 101.) The tibia when affected may show the saber deformity. 
The tibiae are most frequently involved; next in frequency, the radii. 
Gummata may involve the flat bones of the cranium, although such an 
occurrence is comparatively rare. The ''saddle nose" caused by a 
destruction of the septum is a condition not infrequently seen in con- 
genital syphilis. 

The Teeth. — Fairly characteristic signs, first described by Hutchin- 
son, are often shown by the second set of teeth. The first set in no way 
give evidence of the disease. Hutchinson's teeth represent faulty de- 
velopment. They are variously described, according to the deformity 
presented, as notched, "screw-driver," and peg-shaped. (See Fig. 
102.) 




Fig. 102. — Hutchinson teeth. 

Lymph-nodes. — The only lymph-node involvement of significance 
is that of the epitrochlears. General lymph-node involvement is to 
be looked upon as corroborative of other signs of consequence. 

The Eye. — A diffuse interstitial keratitis is one of the most frequent 
manifestations of tardy hereditary syphilis. 

Involvement of Other Structures and Organs. — The spleen is usually 
enlarged, the liver not infrequently. I have seen three cases of brain 
tumor of syphilitic origin. As is well known, any portion of the body 
may be involved in a syphilitic process, and a detailed description of 
the various possibihties is out of place at this time. The symptoms as 
outlined represent the usual manifestations. 

Treatment. — My experience with salvarsan in tardy hereditary 
syphilis has been thoroughly unsatisfactory. As in the treatment 
of tertiary syphihs in the adult, likewise in the treatment of the 
late hereditary form in children, the iodids play an important part. 



SYPHILIS 689 

Much better results, however, are obtained with the so-called 
''mixed treatment." The iodids alone are not sufficient to give 
us our best results, and the results with mercury alone are 
not so prompt and satisfactory as when the two drugs are 
combined. For an average case of periostitis involving the an- 
terior portion of the tibia in a child four years of age, from }^q to 
J^'o grain of bichlorid of mercury should be given daily, combined with 
sufficient iodid of potash to produce the characteristic coryza. This 
may necessitate the giving of from 12 to 20 grains of iodid daily, as 
children vary greatly in their susceptibility to the drug. The mercury 
and the iodid of potash should not be given in one mixture, as the com- 
bination is most disagreeable to the taste. It is far better to give the 
bichlorid in the form of tablet triturates. The iodid of potash is best 
given in a saturated solution, one drop of which represents one grain 
of the drug. This is best taken when dropped into milk after meals. 
Beneficial results from the treatment will usually be apparent in a few 
days. If there is a periostitis, the pain will be the first symptom to 
disappear. 

The administration of the iodid of potash should always be inter- 
rupted, chiefly because of the possibilities of deranging the child's di- 
gestion. I usually give the drug for ten days, followed by a rest of five 
days, when it is again resumed. Proper nutrition in these cases is a 
most important factor in their management. If the iodid is given to 
the point of tolerance, its omission for a few days will not be noticed. 
The mercury is given for weeks continuously in doses of from %o to J^o 
grain three times a day, graduated according to the age. Later, when 
the progress of the case shows that the disease is under control, the two 
drugs should be given alternately, for ten days each. How long this 
treatment should be continued must be determined by each individual 
case. The Wassermann test in these cases is of much service. Patients 
who are apparently cured should be instructed to report to the physi- 
cian every three months. I frequently advise a course of treatment for 
three or four weeks, two or three times a year. A sufficient excuse for 
such action may be the condition of the child, who may show a tend- 
ency toward slow growth and improper nutrition. The patients 
should be kept under observation for years and should be seen at stated 
intervals until the adult period is reached, when the nature of the 
trouble should be explained to them. The disease from which such a 
child is suffering should always be made plain to parents, or at least to 
one of them, in order that the patient may not be allowed to pass from 
under medical observation in ignorance of his true condition. 

Tardy Malnutrition of Syphilitic Origin. — The possible manifesta- 
tions of syphilis in the young, as in the adult, are many. The infection 
may be so severe as to destroy the fetus, or so mild in its effects as to 
make recognition difficult. Not the least interesting and important 
of the cases showing remote manifestations are those in which late mal- 
nutrition is the only evidence of the syphilitic infection. The patients 
are usually thin, sometimes sallow, sometimes pale, with little or no 
adipose tissue. They are almost always undersized as regards height, 
44 



690 THE PRACTICE OF PEDIATRICS 

always underweight; the appetite is poor, and they have but Httle 
endurance and correspondingly little resistance. Those seen by me 
were between three and ten years of age. None of the patients were 
mentally defective. When two such children are seen in a family in 
which both parents are robust, this circumstance is a strong indication 
that the children are suffering from the results of a remote syphilitic 
infection in one of the parents. The physical examination may show 
nothing definitely, and yet the Wassermann reaction prove positive. 

Cases of late malnutrition, non-syphilitic in character, due to poor 
hygiene and faulty feeding, may present symptoms identical with the 
above, so that while the two conditions cannot be differentiated by the 
clinical signs, there may be sufficient grounds for suspicion to warrant 
us in questioning the father, whereupon the history of a primary sore 
with perhaps secondary lesions may be elicited. There may have been 
prolonged treatment, with a subsidence of all the symptoms, and the 
patient may have been pronounced cured and told that he might safely 
marry. Many times have I heard this story when the evidence of 
transmission was before me in the form of a typical case of congenital 
syphilis. 

Treatment. — Treatment of tardy malnutrition of syphilitic origin 
by the supportive and restorative methods used in the cases of non- 
syphilitic malnutrition is without avail. (See Tardy Malnutrition, 
p. 100.) These patients require mercury, either alone or combined with 
the iodids. To the usual methods of treatment with iron, cod-liver 
oil, baths, and massage, there will be but little response, but if bichlorid 
of mercury or the iodid of potash be added, the case will improve. 
The improvement is slow, to be sure, but it is invariable. The child 
should be given the advantage of an outdoor life, with free ventilation 
of the sleeping-room at night. The food should be highly nutritious, 
containing a large amount of proteid. Eggs, meat, milk, and the high- 
proteid cereals, such as oatmeal, are the most valuable. The dried 
legumes, — -peas, beans, and lentils, — given in the form of purees, are a 
valuable addition to the diet. Salt baths at bed-time (p. 780) during 
the entire year, followed by oil inunctions during the cooler months, are 
valuable in restoring a vigorous condition. As these children are al- 
most always anemic, it may be well to combine the bichlorid of mer- 
cury with nux vomica and quinin. For a child from five to ten years 
of age the following prescription has been used with marked benefit: 

I^ Hydrargyri bichloridi gr. ss 

Tincturse nucis vomicae gtt. xc 

Extract! ferri pomati gr. x 

Quininse bisulphatis 5j 

M. Div. et ft. capsulae no. xxx. 

Sig. — One capsule after each meal. 

This is given for ten days, when the bichlorid of mercury in tablet 
form, %Q grain three times daily after meals, is given for ten days. 
During the ten days when the bichlorid is given alone maltine and cod- 
liver oil may be given — one dessertspoonful three times a day after 



TUBERCULOSIS 691 

meals. In these cases iodid of potash is not to be given early in the 
treatment, for the reason that the appetite is usually poor or indifferent, 
and the administration of the drug at this time might further decrease 
the desire for food. The iodid of iron may be used in doses of 10 to 15 
drops, three times daily, if the physician desires to change the form in 
which the iron is administered. 

Duration of Treatment. — Prolonged treatment will usually be re- 
quired. These patients should be kept under close observation for at 
least two years, or until they arrive at adolescence, when they should 
be made acquainted with the nature of the disease. During the entire 
growing period the administration of mercury during one month out 
of every three, or possibly every six, depending upon the child's condi- 
tion, will insure better growth and a more vigorous development both 
physically and mentally. 

TUBERCULOSIS 

Tuberculosis is the condition resulting from an invasion of the body 
by the tubercle bacillus. 

Types of the Infection. — There are two types of the bacillus — the 
human and the bovine. In 132 children between the ages of five and 
sixteen years Park and Krumweide found the bovine type in 33 cases. 
In 20 of these there was a tuberculous cervical adenitis, in 7 abdominal 
tuberculosis, and in 3 generalized tuberculosis. Alimentary origin of 
generalized tuberculosis was apparent in 1, tuberculosis of the bones 
and joints in 1, and tuberculosis of the tonsil in 1. 

Of 220 children under five years of age 59 showed the bovine type. 
Of these, 20 showed tuberculous cervical adenitis; 13, abdominal tuber- 
culosis; 10, generalized tuberculosis — alimentary origin; 5, generalized 
tuberculosis; 8, generalized tuberculosis including meningitis — alimen- 
tary origin; 1, generalized tuberculosis including meningitis; 2, tuber- 
culous meningitis. 

The percentages of bovine infections were as follows: 

Children Five to Children Under 
Sixteen Years Five Years 

Pulmonary tuberculosis per cent. per cent. 

Tuberculous adenitis (cervical) 37 per cent. 57 per cent. 

Abdominal tuberculosis 50 per cent. 68 per cent. 

Generalized tuberculosis 40 per cent. 26 per cent. 

Tuberculous meningitis, with, or without localized 

lesion per cent. per cent. 

Tuberculosis of bones and joints 3 per cent. per cent. 

Park and Krumweide conclude as follows: ^'In children, the bovine 
type of tubercle bacillus causes a marked percentage of the cases of 
cervical adenitis leading to operation, temporary disablement, discom- 
fort, and disfigurement. It causes a large percentage of the rarer types 
of alimentary tuberculosis, requiring operative interference or causing 
the death of the child directly or as a contributing cause in other 
diseases. 

''In young children it becomes a menace to life and causes from six 
and one-third to ten per cent, of the total fatalities from this disease." 



692 THE PRACTICE OF PEDIATRICS 

The bovine infection is largely limited to children, and the fatal 
cases are further limited to infants and very young children. 

A review of the very extensive literature that now exists on this 
subject leads one to the conclusion that about 20 per cent, of the cases 
of tuberculosis in children are of bovine origin. 

Avenues of Entrance. — Tubercle bacilli may enter the body by 
means of the respiratory and alimentary tracts, by means of the genito- 
urinary system, and through the skin. The two latter are very unusual 
modes of entrance. The avenue of entrance of the bovine bacillus is 
the alimentary tract — that of the human type, the respiratory tract. 
In a large majority (60 per cent.) of my cases the patient had been in 
association with a tuberculous individual. 

Illustrative Cases. — Two children, aged six and eight, developed pulmonary 
tuberculosis. They were dispensary patients, and Hved in a small three-story 
tenement house. The fact that the two cases developed at the same time seemed 
conclusive evidence of a common source of infection. Both the father and the 
mother were well, and they, with their two children, composed the family. Upon 
further investigation we found that the janitor of the tenement had advanced pul- 
monary tuberculosis, and that he was not at all careful where he deposited tuber- 
culous sputum. 

Aged people with chronic bronchitis are often carriers of the tuber- 
cle bacillus, and such persons are the most dangerous. They remain 
indoors and infect the rooms. Not suspected of being tuberculous, 
they are careless, they kiss and fondle, and often assume considerable 
care of, the younger members of the family. I have traced several cases 
of tuberculous meningitis to such origin. 

Illustrative Cases. — In a recent case the infection was traced to the grandfather 
whom the child visited for four weeks. 

A baby of nine months, an only child, died from tuberculous meningitis. No 
source of the infection could be discovered until, six months later, the mother de- 
veloped acute pulmonary tuberculosis of a very active type. She undoubtedly 
was suffering from latent tuberculosis at the time of the child's death. The father 
contracted the disease apparently from his wife, and died in two years. In all 
these cases there was a decidedly virulent infection. 

Predisposing Causes. — Among the predisposing causes, age is im- 
portant. The more tender the age, the greater the susceptibility. 
Any illness which decreases the general resistance or lessens the resist- 
ance of the upper air-passages or lungs, predisposes to the disease. 
Thus we see many cases following measles, scarlet fever, influenza, and 
bronchopneumonia. Adenoids and diseased tonsils are eminently pre- 
disposing causes, particularly favoring tuberculous cervical adenitis. 
Heredity is less a factor than is generally supposed. Often what passes 
for heredity is a direct infection from a tuberculous parent, in whom 
the disease has remained dormant in the bronchial glands or elsewhere, 
and does not develop until a late period. 

The close housing of children during the colder months is of no 
little importance as a means of diminishing resistance to the bacillus. 
The habit of frequent change of residence is also a source of infection. 
A family moves into an apartment or tenement with little thought or 
knowledge of the previous occupant, and the owner makes no effort at 



TUBERCULOSIS 693 

painting or cleaning for the new tenants, carrying out only such changes 
as are absolutely necessary. I have known tuberculosis to develop in 
children occupying an apartment in which a tuberculous adult had pre- 
viously been domiciled. Infection may take place through the blood 
of the mother by way of the placental circulation. Cases have been 
reported in our country by Jacobi and Wollstein, in which a tuberculous 
fetus has been born to a tuberculous mother. 

Prophylaxis. — The best insurance against tuberculosis is a vigor- 
ous bodily resistance. At least 85 per cent, of the human race are 
infected some time before the thirtieth year, but, fortunately, the 
great majority of those infected are able to withstand the invasion. 
Observation with the von Pirquet test in different countries, covering 
a large number of children of varying ages, show that from 40 per cent, 
to 70 per cent, react positively. The results demonstrate that a vast 
majority of the human race are infected before the fifteenth year. 
Adenoids and diseased tonsils should be removed from every child who 
possesses them. Children should be allowed to make complete re- 
coveries from bronchitis, bronchopneumonia, influenza, whooping- 
cough, measles, etc. A week or longer from school is a matter of no 
moment in the child's future from the standpoint of knowledge. 
Kissing of children on the mouth should be forbidden. This act is a 
grossly unfair advantage to take of an innocent child. Overwork at 
school, in mines, and in factories predisposes, by fostering close asso- 
ciations and diminishing resistance. 

The reporting of tuberculous cases, and the rigid enforcement of 
hygienic measures relating to the disposal of tuberculous sputum, 
would materially lessen the number of cases. 

Infants and young children up to the fourth year are very suscepti- 
ble to tuberculosis. During this period the child should have absolutely 
no association with an open case in an adult or older child. If 
there is such an association the infant will in all probability develop 
tuberculosis. 

Milk Infection. — The infection of the bovine type is preventable 
by pasteurizing all milk and butter which is not taken from tested 
cows proved free from tuberculosis. The nutritive qualities of milk 
are not harmed by heating, but all children fed on pasteurized milk 
should be given orange-juice. 

Municipal Pasteurization. — Rosenel, Calmette, Von Behring and 
others believe that infants are infected through the intestinal tract, 
the bacilli passing through the mucous membrane of that structure 
without injury and lodge in the bronchial glands or elsewhere in the 
body — remain dormant and go through a process of transmutation 
from the bovine to the human type, producing pulmonary tuberculosis 
(human) in later life. 

Relative Frequency in Different Sites. — Although the tonsil is 
looked upon as a portal for the frequent entrance of the disease, this 
organ itself has been found to be tuberculous in very few instances. 

In 90 per cent, of all cases of tuberculous lymphadenitis the cervical 



694 THE PRACTICE OF PEDIATRICS 

glands are involved, and chronic inflammation in these glands, when 
well advanced, is usually aggravated by the presence of infecting or- 
ganisms of the staphylococcus or streptococcus groups. 

Still has reported important findings in 216 postmortem examina- 
tions following fatalities from tuberculosis in children. In 63.8 per 
cent, he traces the incidence of the disease to the lung; in 29.1 per cent, 
to the intestine; and in 15 of the 216 cases, to the ear. By other au- 
thorities the frequency of primary respiratory infection is estimated at 
65 to 70 per cent., and that of an initial intestinal infection at 15 to 30 
per cent. 

Both Still and Carr report finding caseation of the mediastinal 
glands in 81 per cent, of autopsies on tuberculous subjects, while in a 
proportion ranging approximately from 55 to 60 per cent, the same 
observers found a similar condition in the mesenteric glands. The 
mediastinal glands on the right side are more frequently diseased than 
those on the left. 

Nearly 60 per cent, of tuberculous cases have shown invasion of the 
mesenteric glands; and in 12 of 100 autopsies upon children under two 
years of age, Still found tuberculous peritonitis. 

Abdominal Tuberculosis (Tuberculosis of the Mesenteric Gland; 
Tabes Mesenterica) 

Tuberculosis of the mesenteric glands is not uncommon in the find- 
ings at autopsy upon young tuberculous subjects. Barely is the condi- 
tion sufficiently developed, in this country, to be recognized clinically 
independent of peritonitis. My first postmortem examination upon a 
child, however, was in a case of this character. The patient was three 
months old, colored. I have examined at autopsy two other cases in 
which there was uncomplicated tabes mesenterica with no peritonitis. 
I have diagnosed the condition in three other cases as true tabes 
mesenterica. 

Symptoms. — The symptoms include slow progressive emaciation, 
slight inconstant elevation of the temperature, distended abdomen, 
persistent intestinal indigestion, diarrhea, flatulence, and abdominal 
pain. The pain is colicky in character, and may be very severe and 
continue over a considerable period. 

Diagnosis. — A positive diagnosis is to be made upon one's ability 
to palpate the enlarged glands. For critical abdominal examination 
I very often employ light anesthesia. This renders the examination 
far more satisfactory. The glands in my cases were best felt in the 
right or left iliac fossa. 

The symptoms somewhat resemble those of chronic appendicitis, 
and a rectal examination may be necessary to determine if there is an 
enlargement of the appendix or adhesions or infiltration about it. 

Prognosis. — The prognosis is unfavorable in cases that have devel- 
oped sufficient signs for a diagnosis. Still, who has had a large experi- 
ence in abdominal tuberculosis, states that we are never sure of the 



CHRONIC TUBERCULOUS PERITONITIS 695 

recovery cases. The diseased glands may at any time be the starting- 
point of a general or localized inflammation, with the output of exten- 
sive adhesions resulting in a general tuberculous peritonitis or produc- 
ing local effects interfering seriously with the functions of the intestine. 

Illustrative Case. — About four years ago I performed an autopsy for a colleague 
on a. two-year-old child who had died suddenly with symptoms of acute intestinal 
obstruction. The child had had abdominal trouble during the second year, and had 
been seen by different physicians, one of whom made a diagnosis of tabes mesen- 
terica. The patient improved and three months previous to the fatal termination 
was well, with the exception of obstinate constipation. The postmortem showed a 
most remarkable picture of enlarged glands matted, together by fibrinous exudate, 
which had been poured into the abdominal cavity and had undergone connective- 
tissue formation. The descending colon resembled a hollow tube held in position 
by the surrounding exudate. How the child had lived and had bowel evacuations 
is difficult of explanation. The obstruction was caused by an angle forming at the 
point where the free intestine, filled with gas, joined the fixed portion. 

Treatment. — All measures that will increase the patient's resistance 
should be employed. An out-of-door life and the general management 
advised in treating tuberculosis (p. 364) should be followed. 

Still believes that operative measures are of value. He finds that 
removal of the enlarged glands is to be advised, as thereby eliminating 
a definite focus of infection. At the same time fibrinous bands causing 
pain and symptoms may be broken up. 



CHRONIC TUBERCULOUS PERITONITIS 

Acute tuberculous invasion of the peritoneum may be found in a few 
cases of general tuberculosis. It is of no clinical significance, and has 
been briefly referred to on p. 364. 

Chronic tuberculous peritonitis is a comparativelj' infrequent dis- 
ease in this country. In England and on the Continent many more 
cases are seen. Still, of London, reports 266 fatal cases of tuberculosis 
in children under twelve years of age, 45 of whom died with tuberculous 
peritonitis — a percentage of 16.8. Under two years of age, this author 
found 12 cases of tuberculous peritonitis in 100 tuberculous infants. 

Etiology. — A considerable proportion of the cases are probably due 
to an extension from infected mesenteric glands. Through the lymph 
and blood-channels the bacilli may be carried to the peritoneum from 
any focus. 

Pathology. — The course of the inflammation may be acute or 
chronic, and the changes produced have given rise to a classification of 
several tj^pes of the disease. 

1. The simplest lesions consist of scattered grayish miliary tubercles 
unassociated with the presence of exudate or other evidences of an 
advanced process. This picture is seen in connection with a general 
miliary tuberculosis which may have presented no local clinical signs. 

2. In a second form of the disease, coexisting with miliary tubercles 
which are scattered over the peritoneum in great number, there is a 
marked ascites depending on the predominance of the element of exu- 
dation. The exudate is serous and contains only a moderate amount of 



696 THE PRACTICE OF PEDIATRICS 

fibrin. When the fluid accumulation is large, the intestines are floated 
up and the abdominal cavity is characteristically distended. 

3. A third variety of tuberculous peritonitis is predominantly ad- 
hesive and unaccompanied by the exudation of much fluid. The loops 
of intestines become closely matted together and the omentum is rolled 
up in a firm elongated mass. The typical tubercles are present, but 
have, at many sites, become confluent and been transformed into larger 
foci, or given way to the development of reparative flbrous tissue. The 
amount of fluid exudate is small and may be clear or clouded by the 
admixture of fibrin and flakes of pus. 

4. Finally, the lesions may be of a destructive character, consisting 
of actual ulcerations caused by the disintegration of large caseous foci. 
In such an event, adhesions between intestines, mesentery and omen- 
tum are produced which serve to confine collections of pus. These 
may eventually break forth and discharge externally. Fecal fistulse 
or abscesses between adjacent portions of intestine are not uncommon. 

Types of Bacilli. — Park and Krumwiede found the bovine form in 
20 of 53 cases of tuberculosis between the fifth and sixteenth years. 
In 35 children under five years the bovine bacillus was present in 20 
cases. 

Types of Lesions. — The disease is usually divided pathologically 
into two leading f orms^ — the ascitic and the plastic or fibrous. 

There are few cases of the fibrous type, however, without fluid in 
the abdomen, and few ascitic cases in which there is not some fibrous 
formation. Still found the proportion of the fibrous to the ascitic type 
10 to 1. 

Age of Patients. — The great majority of cases occur between the 
first and third years. Cases developing before the end of the first year 
are rare. 

Symptoms. — Suggestive symptoms in all cases are abdominal dis- 
comfort, pain, and distention from gas or fluid, digestive disturbances, 
emaciation, and persistence of all symptoms in spite of medication and 
careful dieting. 

The Ascitic Type. — In the ascitic form, when the patient first comes 
under observation, the abdomen usually contains considerable fluid. 
This increases rapidly and the abdominal wall becomes distended and 
tense. 

There may be a temperature of lOO'' to 102°F. An elevation of the 
temperature is, however, not invariably present: it is as often absent. 
There is a secondary anemia, and the child becomes emaciated and tires 
readily. A differentiation, however, between tuberculous ascities and 
that due to other causes may not be possible without corroborative 
evidence of tuberculosis elsewhere. Examination of the ascitic fluid 
even in positive cases does not always show the presence of the tubercle 
bacilli. Through absorption of the fluid, cases that belong to the 
ascitic type at first, change to the fibrous. This in my experience is 
not at all unusual. 

The Plastic Type. — In these cases the onset is gradual, the tempera- 



CHRONIC TUBERCULOUS PERITONITIS 697 

ture usually is not high — 100° to 101 °F. There are loss of appetite and 
emaciation. Intestinal indigestion, evidenced by tympanites and 
occasional diarrhea, is common. There may be constipation alter- 
nating with diarrhea, and there is almost always pain. It is the pain 
that usually attracts the attention of the parents to the child's condi- 
tion. The course of this form of the disease is slow and its progress 
may be interrupted by periods of improvement. 

Diagnosis. — It is rare in cases of the fibrous type or in those due to 
mesenteric lymphadenitis not to find nodules in either of the iliac fossae 
or the evidence of fibrous bands in the abdomen. The retracted, thick- 
ened omentum, forming a distinct ridge across the abdomen, is present 
in many cases. This may be confused with the lower edge of the liver. 
Careful palpation, however, will demonstrate the band as thick and 
roughened, and extending well across the abdomen in a downward di- 
rection toward the left side. A space between the band and the lower 
edge of the liver can usually be made out. 

With the palpable mesenteric nodes or the fibrous bands, there will 
be fluid in some amount. An unfolding of the umbilicus, with redness 
about it, producing a condition known as ''pointing," is a suggestive 
symptom. Perforation at this point is not an uncommon occurrence 
in the experience of those who see many cases of this disease. 

Prognosis. — About one-half of the patients recover. I have seen 
pronounced cases make complete recoveries. It is a difficult matter, 
as in the instance cited, to decide when a patient is well. The cases 
with ascites promise better than do those of the fibrous type; and 
yet many of the latter form which promise little make complete 
recoveries. 

Illustrative Case. — A boy three years old developed a tuberculous peritonitis of 
a pronounced fibrous type. The omental band could be seen elevating the skin 
across the abdomen in a distinct ridge. After several months of treatment im- 
provement began, and there was steady progress toward a betterment until the 
bodies of the two upper lumbar vertebrae became involved. The child made a 
complete recovery eventually from both conditions. 

Treatment. — The hygienic and medical management is similar to 
the treament outlined for other cases of tuberculosis (p. 364). Ade- 
quate rest, high proteid diet, open air, and change of climate, when this 
may be supplied, should be provided. Drugs are of value only as a 
means of improving nutritional conditions. A combination which 
seems to possess real value in these cases is the following : 

For a child three years of age : 

I^ Liq. potassii arsenitis nj^xlviij 

Liq. ferri albuminati 3vj 

Syr. hypophosphitum (calcis et sodse) q. s. ad §vj 

M. Sig. — One teaspoonful in water after meals. 

The medication is given for ten days, then omitted for five days, and 
then resumed. Interrupted medication may be continued in this way 
indefinitely. 

Moderate exercise may be allowed if the temperature is normal. 



698 THE PRACTICE OF PEDIATRICS 

Operation. — There appears to be but little unanimity of opinion as 
regards the advisability of operative procedure in tuberculous perit- 
onitis. Some authors are ardent advocates and give statistics to prove 
their contentions; on the other hand, other physicians, with equally large 
experience, disapprove of the operation. My own course is as follows: 
If there is a marked ascites with much discomfort, interfering with 
respiration and heart action through pressure on the diaphragm, opera- 
tion is advised at once. It would seem that early operation furnishes 
the best chance for relief in the acutely active cases. Evidence of 
interference with normal peristalsis, as indicated by persistent consti- 
pation and visible peristalsis, means that intestinal obstruction is 
imminent, and under such conditions immediate laparotomy is advised. 
When the above conditions do not obtain, I have found it advisable to 
postpone operation, and treat the patient along the lines already 
referred to. 

Some of the cases seen by me were absolutely hopeless at the time, 
showing marked tuberculous processes elsewhere, and therefore were 
not considered fit subjects for operation. 

The patient should be weighed once a week. In case of a continu- 
ous loss in weight and strength extending over five or six weeks, with or 
without fever, in spite of the advantage of diet, climate, and medica- 
tion, operation is to be advised, regardless of the stage of the process, 
providing always that there is not active tuberculous process else- 
where. When the weight remains stationary or nearly so, and there 
is no evidence of advance in the abdominal lesions, it is safe to wait for 
a considerable time before undertaking operative measures. 

Heliotherapy in Surgical Tuberculosis. — In the summer of 1912 Dr. 
Rollier, of Lysin, Switzerland, published his results in the treatment of 
surgical tuberculosis at the tuberculosis congress in Rome. In the 
town of Lysin are situated, on the snow-covered mountain, the pavilions 
where his method of heliotherapy is practised. It consists in exposing 
the body of the patient to the sun's rays in open galleries communicat- 
ing with the wards and facing due south. The actual seat of disease is 
uncovered for five minutes only, to begin with, as there must be no 
blistering or burning of the skin ; the next day the region is treated for 
two periods of five minutes each, separated by an interval of half an 
hour; and on the third day these exposures are lengthened to fifteen or 
twenty minutes. At each seance a larger area of skin is exposed so 
that at the end of two weeks the entire body, except the head, is being 
exposed to the rays of the sun. The head usually requires protection 
for a little longer time so as to prevent congestion. Plaster jackets are 
rarely used, while abscesses are aspirated and exposed in the usual 
manner. In the jackets windows are cut so that portions, at least, of 
the body are exposed. 

According to Rollier, improvement is evinced almost immediately. 
Fever disappears, hemoglobin and red cells approach and attain their 
normal standards, while increase in weight is most noticeable. Out 
of 369 cases of surgical tuberculosis treated thus, in 284 (78 per cent.) 



DACTYLITIS 



699 



recovery was obtained; in 48, improvement; in 21 the condition re- 
mained stationary, while 16 (4 per cent.) succumbed. In visceral tuber- 
culosis the results were excellent. In 27 cases of peritonitis and enteri- 
tis there were 17 recoveries, 3 improvements, and 3 deaths. Certainly 
no other treatment has given such results. 

The different rays (blue, indigo, violet) each play a part in the cura- 
tive process as well as the more recently discovered infra-red and ultra- 
violet rays. Some are analgesic, some have a tonic action, and others 
penetrate deeply into the tissues. There is no attempt to utilize any 
particular ray as Finsen did. Experiment has shown that fully 25 or 
30 per cent, of sun's rays are absorbed by atmosphere and dust and 
that to make the treat- 
ment efficient, altitude 
is of prime importance. 

DACTYLITIS 




4 




Fig. 103.— Dactylitis. 



Dactylitis consists 
of a fusiform swelling 
of one or more of the 
phalanges. (See Fig. 
103.) There are two 
forms — dactylitis 
syphilitica and dactylitis 
tuberculosa. 

Pathology.— The 
lesion is the same in 
both types, consisting 
of rarefying osteomye- 
litis. The process be- 
gins in the center of the bone, causing an enlargement of the medullary 
canal. At the same time, particularly in syphilitic types, there is a 
periostitis with deposit of bone cells, so that eventually the bone is of 
much greater circumference than other similar bony parts. 

Suppuration and necrosis occur. A mere shell of bone may remain 
which, on undergoing further necrosis, may result in the loss of the 
finger or toe. The disease does not limit itself to one bone. 

Illustrative Case. — In a recent syphilitic case all the fingers of both hands were 
involved and also the metatarsals of both great toes. The index- and middle 
fingers of the right hand suffered most. On the whole, both hands were alike and 
appeared almost webbed, due to the sweUing of the proximal phalanges, while the 
distal ones tapered in a definite penciled fashion. There was apparently no pain, 
and the infant used the hands with perfect freedom. The x-ray plates showed a 
destructive osteitis involving the bones of both hands. 

The radiograph reproduced in Fig. 104 shows very graphically the 
bone change taking place in tuberculous dactylitis. In radiograph A 
are shown the necrosis that has taken place in first phalanx of the 
middle and little fingers. Radiograph B, taken 10 weeks later, shows 
a re-establishment of the bone structure. Radiograph C shows the 



700 



THE PRACTICE OF PEDIATRICS 



O 




\^ 



.<ei\>^^ 



x\\- 



0^^ 



CO 



^ 



^ r^ 



bD 
O 




bO 



TUBERCULIN 701 

bones entirely restored to normal. The patient, a child of 8 months, 
had the advantage of hehotherapy. 

Differentiation. — Differentiation between the two types from the 
clinical appearance is impossible. When the lesion is multiple, it is 
more apt to be of syphilitic origin, although this is by no means certain, 
as I have seen multiple spina ventosa. The von Pirquet test and the 
Wassermann reaction, in the absence of disease elsewhere, will be re- 
quired to establish the diagnosis, as the symptoms and appearance are 
identical in both forms. 

Treatment. — Aside from the antisyphilitic treatment, the manage- 
ment of the two types is the same. Absolute rest of the parts appears 
to be essential for success. This is best secured by the use of splints, 
which must be kept bound on the fingers for months in such a way as 
effectually to immobihze them. In a recent case of the tuberculous 
form, successfully treated in this way, the finger was kept in splints for 
six months. When abscess and necrosis occur, the case must be treated 
along surgical lines, the immobility of the parts being maintained as 
completely as the conditions allow. 

The Newer Diagnostic Methods 
tuberculosis 

Tuberculin is used as a diagnostic agent to detect early, latent, or 
doubtful cases of tuberculosis; it may be appHed in three different 
ways: suhcutaneously , cutaneously , and in the eye. 

Subcutaneous Inoculation. — The dose used for diagnosis is larger 
than that allowable for immunization purposes, from Ho to 5 or 10 
milHgrams being used, according to the age of the child. If the patient 
is tuberculous, the injection is followed in eight to twenty-four hours 
by a rise of temperature, a certain amount of malaise, tenderness at 
the seat of injection, and rales over the suspected lung area. The re- 
action is general as well as local. The temperature falls within 
twenty-four hours. No reaction occurs in non-tuberculous cases, 
while in 95 per cent, of those of tuberculosis the test is followed by a 
positive reaction. Absolute exclusion of tuberculosis, however, be- 
cause of a negative result, is not possible. The test is applicable 
only to cases which do not run a temperature over 37.7°C. (100°F.), 
and is useful in doubtful and obscure cases. It may be necessary to 
repeat the inoculations two or three times before a positive reaction 
occurs; the initial small dose of Ko milHgram being followed in three 
days by another of one milligram, and again, if necessary in three days 
by another of 3 or 5 milligrams in older children. 

A second subcutaneous test is the puncture or stick reaction of Ham- 
burger, who claims that his is the most sensitive test. In older children 
HoootoKoo milligram of tuberculin is injected just beneath the skin. 
Within twenty-four hours the local reaction begins and lasts for five or 
six days. The redness and induration are visible at the point entered 
by the needle, and also at the place where the injected fluid is deposited. 



702 THE PRACTICE OF PEDIATRICS 

Cutaneous Inoculation. — This method of vaccination with tubercu- 
hn was introduced by von Pirquet. A small superficial scarification 
is made on the forearm, and a drop of undiluted tuberculin is appUed. 
An untreated scarified area of equal size is made at the same time for 
control purposes. In cases of active tuberculosis the reaction begins 
within twenty-four hours. A small red papule forms, surrounded by a 
limited area of redness and induration. In four to eight days the nodule 
has disappeared. The control scarification heals without any inflam- 
matory sign. Von Pirquet himself uses a fine boring instrument in- 
stead of scarifying. The method is most valuable in infants and chil- 
dren under two years of age. A positive reaction is accepted by von 
Pirquet as proof positive of tuberculosis. A negative reaction, on the 
whole, means absence of any tuberculous focus. My own observation 
substantiates von Pirquet 's statement; a positive reaction means 
tuberculosis in almost every case. This we have proved by other 
means, such as examination in spinal fluid and sputum, and autopsy 
findings. 

In the last days of a miliary tuberculosis the reaction fails to appear 
in about half the cases. Furthermore, in cachectic conditions from 
any cause the reaction does not appear. During the eruptive stage of 
measles it is absent in 100 per cent, of tuberculous cases, while in 
scarlet fever the negative result is less constant, the reaction failing 
to appear in 85 per cent, of the cases. After the eruption has disappeared 
a von Pirquet reaction may be obtained. Tuberculous patients suf- 
fering from diphtheria or typhoid fever also fail in some instances to 
react to the cutaneous tuberculin test. 

Differential Cutaneous Reaction. — Detre devised this method of 
diagnosing human from bovme tuberculous infection. He used the 
filtrates of bouillon cultures of human and bovine tubercle bacilli, 
applying them by the von Pirquet cutaneous method, making the scari- 
fications and the applied drop of fluid as nearly alike as possible. The 
diagnosis is determined by the relative size of the resulting reaction 
papules, which Detre carefully measures. Thus far, most observers 
find that in the majority of cases the two reactions are equally marked, 
and it has not yet been established that the differential diagnosis 
between human and bovine tubercle bacillus infection is possible by 
this means. 

The More Inunction Test for Tuberculosis. — Equal parts of old 
tuberculin and anhydrous lanolin are used in the form of a salve. The 
dose is about one gram of the ointment, rubbed into an area of healthy 
skin about 5 cm. in diameter. The application is made in the epigas- 
tric or submammary region, a rubber finger-cot or glove being used to 
rub the ointment into the skin for three-fourths of a minute or more. 
The inoculated area is exposed to the air for ten to twenty minutes, 
and no dressing is applied. It is well to clean the site of the inunction 
with alcohol before applying the salve, and also to ring the inoculated 
area. A control with plain lanolin is made on another part of the skin. 
The reaction manifests itself in ten to seventy-two hours, but in the 



TUBERCULIN SKIN REACTIONS IN INFANCY 703 

majority of cases it does not appear later than the second day. The 
eruption which appears is papulovesicular in character, with an 
erythematous areola around the individual papules. In a severe re- 
action the areolae may coalesce. The papules vary in number from 
very few (1 to 4) to very many (50 to 100). Itching sometimes occurs. 
The eruption persists for several days ; in severe cases it may be appar- 
ent for seven to ten days, and may be followed by pigmentation and 
desquamation. The test is simple and harmless. As a rule, the von 
Pirquet reaction is fully developed several hours before the inunction 
(Moro) reaction. 

Ophthalmo-reaction. — This was first described by Wolff -Eisner and 
shortly afterward by Calmette, and consists of the instillation of one 
drop of 0.5 per cent, solution of tuberculin into the conjunctival sac 
of the healthy eye of the patient. Within twelve hours swelling and 
redness are at their height, and gradually subside in twelve hours more. 

The von Pirquet cutaneous test answers every purpose. 

The advantage of the cutaneous method over the subcutaneous is 
that it obviates the possibility of spreading the tuberculous process, 
since no general reaction follows its application. Both local methods 
are based upon the principle that in the course of a tuberculous infec- 
tion all the cells of the body are sensitized to the products of the 
tubercle bacillus. When, therefore, a minute quantity of such products 
(tuberculin) is brought into direct contact with a sensitized and vas- 
cular tissue like the skin or conjunctiva, a rapid inflammatory re- 
sponse occurs. 

TUBERCULIN SKIN REACTIONS IN INFANCY 

Dr. Alan Brown,* in a study of 650 hospital cases, found that 70 
per cent, of the cases under two years of age giving a positive reac- 
tion proved fatal. The lesions were, with but rare exceptions, general 
in distribution. 

That infants show a high degree of susceptibility to tuberculosis 
was shown by the fact that of 61 infants in whom a definite history of 
exposure could be obtained, 41 responded to the test, and of these, 37 
died of tuberculosis. 

In infancy a negative cutaneous reaction, except in moribund cases 
or in children suffering from any very acute infection, is almost conclusive 
evidence against the existence of a tuberculous focus. 

Among 100 consecutive cases of tuberculosis, 95 gave a positive re- 
action, the remaining 5 patients being moribund on admission to the 
hospital. 

In a child in whom tuberculosis is suspected the test should be re- 
peated if at first it proves negative. 

* "Archives of Pediatrics," July, 1913. 



704 



THE PRACTICE OF PEDIATRICS 



CHART SHOWING THE HIGH DEGREE OF MORTALITY IN INFANTS 
RESPONDING TO THE CUTANEOUS TEST. ALL FATAL CASES 
PROVED TUBERCULOUS EITHER BY AUTOPSY OR THE FINDING 
OF BACILLI IN SPUTUM OR CEREBROSPINAL FLUID 



Age 


Num- 
ber OF 


Num- 
ber 

WITH 

Posi- 


Number of 

Positive 

Cases with 

Autopsy or 


Number of Posi- 
tive Cases 
Proved to Be 
Tuberculous by 


Number 
OF Nega- 
tive Cases 


Number of 
Negative Cases 
Which Showed 
NO Tubercu- 
losis AT 
Autopsy 




Cases 


tive 
Reac- 


Bacterio- 
LOGic Exam- 


Autopsy or Bac- 
TERiOLOGic Find- 


Came to 
Autopsy 








ination 


ings 






1 to3 


62 


3 


3 


3 


10 


10 


months 






' 


or 100 per cent, 
of + reac- 
tions. 






3 to 6 


102 


7 


6 


6 


13 


13 


months 








or 85 per cent. 






6 to 12 


218 


43 


35 


35 


19 


18 


months 








or 81 per cent. 




Test not re- 
ported in 
one case. 


12 to 18 


156 


37 


20 


20 


15 


15 


months 








or 54 per cent. 






18 months to 2 


112 


24 


15 


15 


4 


4 


years 




114 




or 62 per cent. 






Total, to 2 


650 


79 


79 


61 


60 


years 








or 70 per cent, 
of + reac- 
tions. 







CHART SHOWING THE BEARING OF EXPOSURE TO TUBERCULOSIS 
ON THE MORTALITY IN THE INFANT 



Age 


Number of 

Cases 


Number of 

Cases with a 

Definite 

Family History 


Number of Cases 
with Definite 
Family History 
THAT Reacted 


Mortality of 
Cases with Defi- 
nite Family 
History that 
Reacted 


1 to 3 months 

3 to 6 months 

6 to 12 months 

12 to 18 months 

18 months to 2 

years 


62 
102 
218 
156 
112 


4 

8 

30 

10 

9 


3 

4 

20 

10 

4 


3 
4 
20 
6 
4 


Total, to 2 years 


650 


61 


41 


37 

or 60 per cent. 

of those giving 

a history o:" 

contact. 



WASSERMANN TEST FOR SYPHILIS 

The Wassermann serum reaction is the appUcation of the comple- 
ment fixation or deviation test to the diagnosis of syphilis. As intro- 
duced by Wassermann, Neisser, and Bruck, it required the use of 
guinea-pig complement, the serum to be tested, antigen consisting 
of extract of syphilitic liver, and a sheep's hemolytic system. By 



NOGTJCHI BUTYRIC-ACID TEST 705 

sheep hemolytic system is meant an immune rabbit serum prepared 
by inoculating rabbits with washed sheep's erythrocytes, and a sus- 
pension of washed red blood-cells of the sheep. In the presence of 
fresh guinea-pig serum (complement) such an immune serum has the 
power of hemolyzing the red blood-cells. In the same way human 
hemolytic system means the combination of washed human erythrocytes 
and an immune serum prepared by inoculating rabbits with washed 
red blood-cells of the human type. 

If the serum to be tested contains immune bodies specific to the 
antigen, used, these will, in the presence of complement, unite with each 
other and bind the complement. The addition of the hemolytic sys- 
tem will then cause no change in the tubes, i. e., hemolysis will not 
occur. If the antigen and the immune serum are not specific, then the 
complement is left free to unite with the hemolytic system and hemoly- 
sis occurs. This is called the complement fixation or deviation test. 

As simplified by Noguchi, the test requires much smaller quantities 
of guinea-pig complement, the serum to be tested, antigen consisting 
of human or animal tissue extract, and human hemolytic system. For 
practical purposes one cubic centimeter of the patient 's blood will give 
an ample amount of serum for the test. 

The Wassermann seroreaction is positive in 98 per cent, of cases of 
congenital syphilis, but only in 66 per cent, of latent syphilis. During 
the primary stage of acquired syphilis 90 per cent, of the cases give a 
positive Wassermann test, during the secondary stage, 96 per cent.; 
and during the tertiary stage, 83 per cent, react positively. 

Craig has found that the reaction may disappear from two to four 
weeks after the institution of mercurial treatment, but it may return 
when the treatment is stopped ; therefore it is not established that the 
disappearance of the reaction justifies the conclusion that the disease 
has been cured, and that treatment may be discontinued. 

Noguchi found that after treatment with salvarsan the reaction 
may disappear within two weeks in promptly cured cases, although it 
may not do so for four or five weeks. 

NOGUCHI BUTYRIC-ACID TEST FOR SYPHILIS 

This test is based upon the fact that the globulin reaction in the 
blood-serum and in the cerebrospinal fluid is increased in syphilis. In 
the case of the blood-serum the test is too complicated to be used any- 
where except in a highly equipped laboratory, and, moreover, it is not 
needed in children, since Wassermann 's serum reaction answers all 
practical purposes. Applied to the cerebrospinal fluid, the Noguchi 
test is very simple and is carried out as follows : One or two-tenths of 
a c.c. of cerebrospinal fluid, which must be absolutely free from blood, 
is mixed with 3-^ c.c. of a 10 per cent, solution of butyric acid in normal 
saline and boiled. Then }{q c.c. of normal sodium hydroxid solution 
is quickly added, and the whole is boiled for a few seconds. A granu- 
lar or floccular precipitate indicates a positive reaction. The appear- 
45 



706 THE PRACTICE OF PEDIATRICS 

ance of the precipitate within a few minutes indicates a considerable 
increase in globuhn, while weaker reactions may not appear for an hour. 
Two hours should be the time limit. 

Normal cerebrospinal fluid with this test gives a slight opalescence 
and occasionally turbidity, but the granular precipitate does not occur 
at all or only after the time Hmit has been reached. 

A positive reaction occurs with the cerebrospinal fluid from any case 
of syphilitic or parasyphilitic affection, and also in all acute inflamma- 
tions of the meninges, whether due to the meningococcus, the tubercle 
bacillus, the pneumococcus, the streptococcus, or the influenza bacillus. 
The reaction is also positive in the early stage of poliomyelitis. Such 
conditions can, of course, be readily differentiated from syphilis. In 
acute luetic meningitis the presence of Treponema pallidum in the cere- 
brospinal fluid will serve to exclude the other forms of meningitis. 
Such a case has been reported by Rach* in a child four months old. In 
hydrocephalus, the cerebrospinal fluid gives a positive butyric acid 
test in cases which are of syphilitic origin. When the amount of cere- 
brospinal fluid is increased without inflammation of the meninges, as 
sometimes happens in pneumonia, the fluid does not give a positive 
butyric acid test. 

In children Noguchi 's test is most valuable in differentiating be- 
tween inflammatory and non-inflammatory conditions of the meninges. 

LUETIN TEST 

The luetin test was originated by Noguchi, and is based upon the 
fact that individuals who have been affected for some time with certain 
pathogenic organisms develop a hypersensitiveness to those organisms 
or their constituents. Emulsions of pure cultures of Treponema palli- 
dum killed by heat are prepared, and 0.057 c.c. injected into the skin 
of the upper arm by means of a very fine needle. A control is made on 
the other arm. In positive reactions a red, indurated papule forms 
within twenty-four to forty-eight hours, and is surrounded by a dif- 
fuse zone of redness. Induration and redness increase for three or 
four days, then subside, and the thickening disappears within a week. 
In cases of late hereditary syphilis, the papule, instead of subsiding, 
may go on to the formation of a pustule, which heals within a week, 
leaving almost no scar. Very rarely the reaction may be delayed, so 
that after three days the result is called negative, yet after ten days or 
longer small pustules form and heal in the usual way. Marked con- 
stitutional symptoms very rarely accompany the reaction. A slight 
rise of temperature lasting for a day is the rule in positive cases. 

In non-syphilitic patients there appears, twenty-four hours after 
the application of the emulsion, a small area of erythema without pain, 
itching, or induration. Occasionally a small papule forms within 
twenty-four to seventy hours; it also disappears without induration. 

The reaction is apparently specific for syphilis, and persists as long 
*''Jahrb. f. Kinderh.," 1912. 



THE WIDAL REACTION 707 

as Treponema pallidum survives in the body. It is specially useful in 
late cases in which the spirochete can no longer be demonstrated micro- 
scopically and in which the Wassermann reaction is indecisive. It 
seems to outlast the seroreaction after antisyphilitic treatment has been 
given. In cases of hereditary syphilis it is present in 91 per cent, to 
100 per cent, of the cases. 

THE WIDAL REACTION FOR TYPHOID FEVER 

To make Widal tests it is necessary to keep in stock a well-agglu- 
tinating strain of typhoid bacillus. A bouillon or agar culture which 
has grown not longer than eighteen to twenty hours should be used for 
the reaction. The blood to be tested should be obtained in a small glass 
tube of the Wright pattern, 0.5 to 1 c.c. in amount, sealed at both ends, 
and the serum allowed to separate. Sterile physiologic salt solution 
is used as the diluent. A porcelain palette with six or more cup- 
like depressions is a convenient receptacle for holding the dilutions, if 
the microscopic method is used. 

By means of a capillary tube marked by a wax pencil 1 drop of 
serum and 9 drops of salt solution are mixed in one of the palette cups, 
making a dilution of 1 : 10. From this stock other dilutions are made; 
1 drop to 4 of salt solution equals a dilution of 1 : 50, etc. The addi- 
tion of 1 drop of culture to 1 drop of a 1 : 10 dilution of serum makes a 
dilution of 1:20. This is examined on a hollow slide with a No. 7 
lens. Controls of the culture alone, and of culture plus normal serum, 
should be made at the same time. Cessation of motion and clumping 
of the bacilli within one-half to one hour, in a dilution of 1 : 40 or 
1 :60, constitutes definite proof of typhoid infection. 

The microscopic method should be employed by preference, 
and the dilutions made in small test tubes. The tubes are placed 
in the incubator at 37.5°C. for one hour and then in the ice-chest 
over-night. The reaction can be read at a glance. The clumped 
bacilli fall to the bottom of the tube and leave the serum quite clear, 
while the control remains turbid and smooth. The quantity of serum 
required is very small, 0.2 cm. being sufficient to make all necessary 
dilutions. Each tube may contain 0.8 cm. of diluted serum and 0.2 cm. 
of bacillary suspension, making a total of 1.0 cm. Agglutination 
in a dilution of 1-40 or 1-60 may be looked upon as a positive reaction. 

With blood dried on a slide the test cannot be accurately made. 
Cultures of typhoid bacilli killed with formalin have been used for mak- 
ing the Widal test, but the method has nothing to recommend it. 

The Widal reaction does not give positive results before the end of 
the first week or the beginning of the second week of typhoid. It may 
continue to be positive throughout convalescence and for a period of 
six to eight weeks. Occasionally its appearance is deferred until con- 
valescence or until a relapse comes on, but it is present at some 
time during an attack of typhoid fever in over 95 per cent, of all 
cases. 



708 THE PEACTICE OF PEDIATRICS 



ANAPHYLAXIS 



The second introduction of a foreign soluble proteid at an appro- 
priate interval after the first introduction of that same proteid causes a 
train of symptoms designated by the term anaphylaxis. The first dose 
sensitizes the organism, while the second dose intoxicates. The time 
required for sensitization is ten days or longer, and its duration has 
been found to be as long as seven years. 

The therapeuti-c use of immune sera, the majority of which are de- 
rived from horses, gave rise to anaphylactic phenomena which von 
Pirquet and Schick recognized and called serum disease. Some pa- 
tients react after a first dose of serum, the symptoms appearing eight 
or ten days after its injection, and consisting of fever, skin eruptions, 
muscle and joint pains, and glandular swellings. Such patients, after 
the administration of a second dose, develop symptoms after a few hours 
or only after several days. The immediate reaction is characterized 
by a local edema at the site of the injection, increasing slowly for 
twenty-four hours, and then disappearing in two to five days. Fever 
and skin eruptions are also present, and in a small percentage of cases 
nausea, vomiting, and even collapse may occur. When the symptoms 
are delayed for several days, they usually occur suddenly and disappear 
within a day. They are similar to those following the injection of the 
first dose of serum. 

In individuals who are asthmatic or afflicted with an idiosyncrasy 
to the odor of horses, a first dose of horse serum may cause an attack 
of respiratory distress with cyanosis or else of cardiac weakness with a 
fatal ending. In such cases we must assume that the sensitization was 
either inherited or acquired through the lungs or through the stomach. 
Experimental data support all three assumptions. 

The tuberculin reaction is a local anaphylaxis in individuals sensi- 
tized to the proteids of the tubercle bacillus. 

Hay-fever is a local anaphylaxis to the protein constituent of cer- 
tain pollens. 

Drug and food idiosyncrasies are anaphylactic in character. 



XVIL UNCLASSIFIED DISEASES 
RHEUMATISM 

In a considerable proportion of the population there exist certain 
physical characteristics which set these individuals apart in a class by 
themselves. The constitutional condition referred to is well recognized, 
and various designating terms have been applied to it, such as the 
rheumatic diathesis, the rheumatic complex (Still), lithemia (Osier), 
and lithemic diathesis. The condition is, to be sure, but little under- 
stood. Nevertheless, if we admit that rheumatic fever (acute articular 
rheumatism) is due to a specific infecting agent, we must also admit 
that there is a favorable field for activity of this agent in certain 
members of the human race. Children who have the rheumatic 
symptom-complex as described below are those who most frequently 
develop acute rheumatism — articular (rheumatic fever) and endo- 
cardial (endocarditis). 

The more prominent features of the rheumatic symptom- complex 
comprise lack of resistance to infection of the respiratory mucous 
membranes and the tonsils; pronounced lack of nervous balance, mani- 
fested by habit spasm; and a tendency to a spasmodic condition of 
the respiratory tract, as seen in bronchial spasm and catarrhal laryn- 
gitis. Another peculiarity, as relates to the nervous system, is absence 
of control during play; the patients become much excited, and waste 
much energy over trifles. In my consulting-rooms I have seen such 
children in ceaseless activity, which they apparently could not control. 
They are very apt to lack concentration. They are the children who 
have frequent ''growing pains" and suffer from periodic stomach and 
intestinal crises. They are, furthermore, subject to eczema and urti- 
caria. Children of this type are the offspring of those who have been 
similarly affected, or who have what they have learned to designate 
as rheumatism, lithemia, gout, uric-acid diathesis, etc. 

Often in the offspring of these individuals will be found a combina- 
tion of the above tendencies; the association of habit spasm, chorea, 
and endocarditis; of eczema, articular rheumatism, spasmodic bron- 
chitis, asthma, tonsillitis, catarrhal laryngitis, and frequent rhinitis; 
of tonsillitis, growing pains, chorea, endocardial and articular rheuma- 
tism; the association of cyclic vomiting, tonsillitis, and the nervous 
manifestations of bronchial spasm with acute bronchitis. In two boys, 
brothers, who had cyclic vomiting, there was invariably an attack of 
tonsillitis first and then the vomiting, which was in turn followed by 
asthmatic bronchitis. None of the attacks were very severe, but each 
time the same sequence was carried out. I have witnessed the above 
associations in too many cases to ascribe them to a coincidence. 

709 



710 THE PRACTICE OF PEDIATRICS 

Further, it is this type of child who develops articular rheumatism and 
endocarditis. 

Question: Has this class of children rheumatism? The answer is 
not easy. They are suffering from a toxic process which manifests 
itself in different ways, even in the same child, and often in a way that 
bears no relation to normal growth and development. The condition, 
whatever it may be, constitutes an entity. Examination of the blood 
and urine tells us nothing of consequence. It is this ''entity" that 
furnishes the field of action for the immediate pathogenic agent of 
acute rheumatism, as evidenced by the joint and heart involvement. 
Whether chorea is to be placed in this class or is a manifestation of 
selective action of the systemic toxemia is a matter to be decided. 
Poynton and Paine claim to have demonstrated the diplococcus in 
the cortex. 

Etiology. — The chemicophysiologic defect appears to be in the liver, 
in the nature, probably, of defective oxidation. At any rate, the usual 
bodily functions are not apparently involved. If the patient of this 
type shows physical defects, it is more from the effects of the various 
ailments occasioned than from the results of the toxemia on the organs. 

The age incidence is of interest. Infants who suffer from eczema, 
who are susceptible to bronchitis, and in whom it is of the spasmodic 
type, often show the rheumatic tendencies later in life. The more 
active manifestations, however, do not appear until the child has passed 
the period of infancy. 

The observations and conclusions arrived at have been made in 
private practice. The hospital does not furnish an opportunity for 
observations on a child, carried through several years, as is necessary 
in order to know the patient from every standpoint. Those who have 
not had a large private work with children for a considerable period, or 
who have not carefully watched their patients, will not appreciate the 
conclusions expressed. 

Treatment. — It is obvious that children of the above type show a 
particular predisposition to certain affections, and a decided lack of re- 
sistance to a particular form of infection — that which occasions acute 
rheumatism. The prevention of cyclic vomiting, spasmodic bronchitis 
(recurrent), chorea, and the other conditions referred to depends upon 
a proper management of the vice of constitution. In tonsillitis two 
factors are operative: the vice of constitution predisposes to attacks, 
producing diseased tonsils, which adds the feature of local infection of 
different kinds, and which necessitates the removal of the tonsils. 
Growing pains, habit spasm, tendency to recurrence of eczema, and \ 
the various nervous manifestations enumerated may be controlled 
largely through right treatment of the ''rheumatic complex." 

The first and most important step in the treatment relates to diet. 

Diet. — These children have a poor fat and sugar capacity, particu- 
larly for cane-sugar and cow's-milk fat. The nearer the approach to 
a vegetable and cereal diet, the better for the patient. 

The nitrogenous foods allowed are poultry, fish, and egg-whites. 



RHEUMATISM 711 

Sugar of the arts is not to be permitted. Vegetables and stewed fruits 
and skimmed milk puddings may be freely used. Skimmed milk or 
buttermilk may be given with the morning and evening meal. All 
cereals are permissible. 

It will be seen that there is no trouble in establishing a well- 
balanced ration. Children will readily learn to do without sugar. 
There is little or no trouble in feeding cereals without sugar. With 
stewed fruits and puddings, saccharin may be used in small amounts. 
I have many children taking stewed fruits, cereals, and puddings with- 
out a particle of a sweetening agent. Puddings and junket are to be 
made with skimmed milk. The fat in the egg-yolk is particularly 
toxic to some of these children, particularly those who have cyclic 
vomiting. Egg-yolks are accordingly not used in puddings. When 
one whole egg would ordinarily be used, the whites of two eggs are 
used instead. A custard may be made as follows: 

White of one egg. 
Saccharin. 

One-third cup scalded skimmed milk. 
10 drops of vanilla. 
10 grains salt. 

Stir white of egg with silver fork. Add milk gradually, salt, and flavor- 
ing. Strain and bake somewhat longer than for ordinary custard. 

In many instances I have seen rheumatic children suffering from 
some one or more of the above-mentioned conditions, together with 
anemia and a stationary weight, coated tongue, and loss of appetite, 
make astonishing gain without other treatment when the sugar and 
cow 's-milk fat were removed from the diet. Three meals a day should 
be given. A free daily bowel evacuation is to be provided for if consti- 
pation is a feature (p. 237). 

If there is much malnutrition, the scheme of hving, as suggested in 
tardy malnutrition, is carried out (p. 100). 

The Bath. — The child should be given a bath at bedtime, followed 
by a cold splash or douche. After the bath, while the feet remain in 
the warm water, a quart or two of cold water should be thrown over the 
body. The degree of cold may vary — 80°F. to 70°F. at first; after a 
week or two water as it runs from the faucet may be used, regardless 
of the season, if the child enjoys it. After the cool douche the patient 
should be vigorously rubbed with a bath-towel and put to bed. 

Drugs. — The only drug necessary, other than perhaps an appetizer 
or a laxative, is bicarbonate of soda, which should be given in inter- 
rupted dosage — from 15 to 30 grains, three times daily, depending upon 
the age and requirement. The soda is to be given after meals for ten 
days, with a free interval for five or ten days, when it may be resumed. 
After a period of a few weeks the soda may be discontinued, but the 
diet must be kept up indefinitely. These children cannot bear alcohol, 
and it should not be included in their tonic or restorative medication. 
When there is a high degree of systemic poisoning which resists the 
above measures, sodium salicylate — rarely more than 5 grains — should 
be given three times a day, after the interval method, with the bicarbon- 



712 THE PRACTICE OF PEDIATRICS 

ate of soda. True salicylate, that made from wiiitergreen oil, should 
always be advised. 

All the measures suggested, without the withdrawal of sugar and 
free fat largely from the diet, are of little avail. 

Illustrative Ca^cs. — ra-sf 1. — A case which is characteristic of many was that of 
a boy. two and one-half yeai-s of age, a scion of one of Anierica's most noted fan\ilies. 
When the boy came under my care lie was having periodic attacks of catarrhal colds, 
associated with cyclic vomiting. The attacks would last for two or three days and 
were not very severe. There was rarely fever. He had been treated for these 
repeated colds by different physicians with expectorant drugs and local chest 
applications, all of which, as might be expected, were without effect. He was given 
the dietetic and drug management, as indicated above: and notwithstanding the 
fact that there had been attacks every fourteen days, there has been but one attack 
in the two years under treatment. First cousins of the child have habitual colds 
with spasmodic broi\chitis. 

Case 2. — A most remarkable case was that of a girl who came imder my care in 
early infancy for an intense and obstinate eczema. From this she recovered, and 
when one year of age developed cyclic vomiting. During the next two years there 
were frequent attacks of cyclic vomiting, spasmodic laryngitis, and bronchial 
asthma. The association of these conditions has been previously referred to. 

Recurrent Bronchitis. — Asthmatic bronchitis is often dependent 
upon the rheumatic state, and repeated attacks suggest the degree of 
the vice of constitution. 

Illustrative Ca^es. — Case 1. — A girl eight years old came under my care because 
of repeated attacks of bronchitis. The mother, a woman of unusual education 
and refinement, stated that the child had had an average of two attacks of bron- 
chitis monthly during the previous year, and at least one attack every month since 
she was five years of age. On my expressing some doubt as to the freqiuMicy. the 
mother stoutly niaintained that her statement was correct. The fan\ily lived in 
Brooklyn, and had been told that the child coidd not remain there during any por- 
tion of the year. She had spent the colder months at different winter resorts, with 
very little, if any, resultant etYect upon the severity or frequency of the attacks. 
The child was pale and inclined to be overstout. There had been no other illness 
of consequence. The attacks were peculiar in that they were of short duration, 
but very severe. There was usually a temperature range from 100'"'' to lOl^F., 
associated with cough, ditficulty in breathing, and occasional attacks of marked air- 
hunger. The attacks were always accompanied by severe coryza. The patient 
came to me at the end of an attack. An examination of the chest showed through- 
out a fairly even distribution of mucous rales involving the smaller tubes. Aside 
from the bronchitis and secondary anemia, the examination was negative. The 
child had attended school at irregular intervals, but only for a few weeks of her 
life. While getting the history I asked, as a matter of routine, if the child snored or 
if she were a mouth-breather. This caused the mother to ren\ark that the child 
had been under the care of throat specialists at ditYerent times, and each physician 
had removed a set of tonsils and a set of adenoids! The mother did not think that 
there was very much left. There was no sign of a tonsil and the nasopharynx was 
free. In spite of a norn\al rhinopharynx, the colds had continued. In taking the 
history I had learned that the family was rheumatic on both sides for at least tliree 
generations. The mother claimed to have suffered a great deal from rheumatism. 
In getting the personal history I asked if the child was fond of red meat. The 
reply was that she lived on it, and cared for little else, with the exception of sugar. 
Here was a girl, eight years of age, who would not drink milk until sugar had 
been added to it. Cereals, stewed and raw fruits were loaded down with sugar 
before she would touch them. 

In my instructions as to the treatment, red meat was allowed once every 
second day and sugar was reduced to a mininuun — probably not more than one- 
fifth the usual amount being given. The child was to be bribed, if necessary, to 
eat green vegetables, cereals, and fruits. Expectorant and cough mixtures were 
discontinued. She was given 20 grains of the bicarbonate of soda and 20 grains of 
the salicylate of soda daily for three weeks. Later the cirug treatment was con- 
tinued at intervals during the remainder of the winter. She passed through the 



ACIDOSIS 713 

following winter without a sign of rhinitis, bronchitis, or asthma, although she 
continued to live in Brooklyn. 

Case 2. — Another case somewhat similar was sent to me by a well-known rhin- 
ologist. The patient, a girl seven years old, had suffered from repeated attacks of 
bronchitis and asthma and had been confined to her home a greater part of each 
winter. Her general condition was thoroughly wretched. ^ Her family physician 
had attributed the condition to enlarged tonsils and adenoids, and the child had 
been sent to New York for operation. The operation was performed, and the 
child returned to her home. As a result the patient could breathe easier and sleep 
better, and suffered much less during her attacks of asthmatic bronchitis; but the 
frequency of the attacks was in no way affected. Early the following summer the 
patient was again taken to the rhinologist, who, finding the condition of the upper 
respiratory tract satisfactory, asked me to take charge of the case, remarking that 
he had "cut everything in sight and out of sight!" The treatment outlined above 
was instituted, and while the results were not so flattering, the condition was 
much improved; only three attacks occurred during the next twelve months, and 
the child gained 15 pounds in weight. 

Repeated inflammatory involvement of the mucous membrane of the upper 
respiratory tract in children, particularly in the absence of enlarged tonsils and 
adenoids, strongly suggests a rheumatic element as a prominent causative factor. 

There are other conditions, apparently of rheumatic origin, which are not 
associated particularly with the common manifestations. 

Rheumatic Pleurisy. — Of this I have seen four cases. There was no pneu- 
monia and no lung involvement of any nature. The fluid was sterile, and the 
patients never, in the years under observation, had further lung signs. The 
amount of fluid in each case was large. All the patients came for treatment 
because of interference with respiration. If there had been fever, it had in each 
instance subsided before the case came under observation. There was no pain and 
no evidence of discomfort other than the cyanosis caused by pressure. 

In two of the cases there was a distinct history of rheumatism. These children 
were between two and six years of age. 

Treatment. — The diet was given as outlined, with salicjdate and bicarbonate 
of soda in dosage suitable for the age, with the result that in all the patients there 
was a complete absorption of the fluid in less than a week. 

Peliosis Rheumatica.— In this unusual affection, which appears to be of 
rheumatic origin, purpura is a prominent symptom. In my patients the purpuric 
area has always been over the anterior portion of the lower extremities, and in 
every instance the disease has occurred in a patient who had had previous attacks 
of rheumatism or chorea, or in whom the rheumatic element was prominent, as 
shown by recurrent tonsillitis or recurrent bronchitis. A further proof of the 
rheumatic origin of the disease is the fact that the cases usually yield readily to 
treatment for rheumatism. 

Treatment. — In one of my patients there were two distinct attacks, both of 
which yielded fairly well to the salicylate of soda and the iodid of potassium. 
The medication and diet are the same as those suggested for rheumatism. In 
case erythema nodosum accompanies the condition, local measures for the relief of 
pain (p. 590) will be necessary. 

ACIDOSIS 

Acidosis is a condition in which there is a diminution of the alkali 
reserve of the body fluids especially of the blood, usually attended by 
an excessive formation of acids with its resulting clinical symptoms. 

Etiology. — An alteration of the equilibrium and normal relationship 
of the alkalies and acids in the body is the direct exciting cause. The 
blood, in order for life to exist must be maintained at a very constant 
reaction which is slightly alkaline, and there must be, within narrow 
limits, a certain excess of bases over acids. Any change from the 
normal toward the side of acidity tends to inhibit numerous sensitive 
metabolic processes in the organism, and acidosis results. 

Pathology. — Metabolic products, especially carbonic acid are con- 
stantly being formed in the tissues and poured into the blood to be 



714 THE PRACTICE OF PEDIATRICS 

transferred to the lungs for elimination. This would tend to alter its 
normal slightly alkaline reaction to one strongly acid were it not for the 
alkaline reserve formed by bicarbonates both in the blood and tissues, 
the alkaline phosphates of sodium and potassium and the alkali pro- 
teins, in conjunction with efforts of elimination by the body. The 
slightest change in the direction of acidity is sufficient to stimulate the 
respiratory center through the agency of the carbon dioxid contained 
in the blood. The increased pulmonary ventilation removes the excess 
of carbon dioxid and the blood returns to its original state, as the res- 
pirations lower the concentration of carbon dioxid in the lungs and thus 
allows it to pass from the tissues where it is in greatest tension to the 
blood and thus to the lungs where the tension is lowest. Certain non- 
volatile acids as sulphuric and phosphoric, also cause, when formed, 
increased pulmonary ventilation and hyperpnea, as they remove some 
of the alkaline reserve of the blood, thus leaving more of the carbonic 
acid, normally produced by the tissues, to be eliminated through the 
lungs. These acids are for the most part eliminated through the kid- 
neys which have the power to excrete an acid urine from a practically 
neutral fluid, leaving behind an alkali reserve for further neutralization 
purposes. An interference with the elimination of acids as well as their 
over-production may therefore cause acidosis. A final and very 
efficient means of preserving the alkaline balance lies in the ability of 
the body to form the alkali, ammonia, from urea a neutral substance, 
which thus adds greatly to the alkali reserve. 

Symptoms. — Acute acidosis in children usually manifests itself in 
two ways, a peculiar symptom complex, seen in infants and in recurrent 
or so-called cylic vomiting in older children. In the former, hyperpnea 
is one of the earliest and most constant symptoms. The majority of 
cases occur in infants who are of the marasmic type, or suffer from mal- 
nutrition and who have finally a severe attack of diarrhea, following a 
digestive disturbance. The hyperpnea is associated with an ashen 
gray color of the skin and a peculiar pallor but no cyanosis. At first 
there is great irritability and restlessness which is succeeded by a con- 
dition of stupor and eventually coma. The eyes become deeply sunken 
and staring, the mouth and lips dry and parched, the fontanelle is de- 
pressed and the respirations are of a deep and sighing character, with- 
out pause and usually labored. On being aroused from the stuporous 
state marked irritability is present, the cry sounding as though in pain. 
The temperature curve shows marked fluctuations, not usually going 
above 101. 5°F. A polymorphonuclear leukocytosis ranging from 
10,000 to 20,000 is found. A very scanty secretion of urine often 
amounting to anuria is frequent. The stools are usually abundant and , 
of a watery consistency. Determinations upon the expired or alveolar ! 
air show a marked reduction in the carbon dioxid tension which may 
fall as low as 12 to 15 mm. of mercury from the normal of 35 to 45 
mm. There is a great tolerance for alkalies, as much as five to ten times 
the usual amount being needed to bring about an alkaline reaction of 



ACIDOSIS 715 

the urine to litmus, and keep it alkaline for 12 or more hours. Acetone 
is not usually found in the urine even in the most severe cases. 

Treatment. — Alkalies must be given promptly, and in sufficient 
quantities to bring the blood back to the normal reaction. Sodium 
bicarbonate answers the purpose best. A 4 per cent, solution for intra- 
venous use best answers the purpose especially where rapidity of 
action is desired, and should be given in amounts of 75 to 150 c.c. 
depending on the age of the infant. This may be repeated in 3 to 4 
hours if the hyperpnea has not disappeared. The superior longitu- 
dinal sinus in infants offers a very convenient avenue of administra- 
tion or the external jugular veins. In older children the median 
basilic may be used. Soda in doses of 20 to 60 grains should be given 
by the mouth every two hours until the urine is alkaline to litmus. 

As the activity of the kidneys is at a low ebb when acidosis develops, 
they should be stimulated by water or salt solution given freely by 
mouth, rectum, subcutaneously or intravenously. (For transfusion 
of citrated human blood in acidosis see p. 786.) 

Cyclic Vomiting (Recurrent or Periodic Vomiting) 

True cyclic vomiting or recurrent vomiting is one of the manifesta- 
tions of acidosis, p. 714. Children who suffer from dilatation and 
ptosis of the stomach (p. 177) often suffer from periodic vomiting, 
likewise those who have mechanical intestinal defects (p. 208) and 
chronic appendicitis. In these cases, however, the seizure is not 
prolonged and there is no air hunger, no great prostration, and no 
fatalities. 

There may be acetonuria as there is in any other acute disorder in 
children, without diminished alveolar air tension. The nature of the 
seizure is quite apart from the vomiting of acidosis. 

Etiology. — Children who have cyclic vomiting often show varying 
nervous phenomena, such as habit spasm, chorea, recurrent spasmodic 
croup, and spasmodic bronchitis. Rachford was the first to designate 
the underlying condition as a gastrointestinal lithemia. 

Secondary Etiologic Factors. — There are certain associated conditions 
which may precipitate an attack in a susceptible subject. Habitual 
constipation with the defective elimination is present in some cases. 
In other cases there is an associated intestinal crisis, with vomiting, 
high fever, and a sharp diarrhea. In others the onset may usher in a 
pneumonia or one of the exanthemata. Fright and fatigue and 
unusual excitement may play a part in inducing an immediate attack. 
Each of these factors, however, represents the spark that ignites the 
powder. If the condition of systemic intoxication did not exist, any of 
the influences mentioned would not produce the vomiting. Recently 
Runyon reported six cases of recurrent vomiting cured by the removal 
of a chronically diseased appendix. 

There are also seasonal influences. When the child can exercise and 
perspire, when he runs much and plays hard, elimination is better, and 



716 THE PRACTICE OF PEDIATRICS 

in many cases fewer attacks occur. Repeatedly, in getting the history 
of these cases I have heard that there are no attacks between May and 
October. 

Symptoms. — The vomiting periods occur periodically. I have had 
cases in which the attacks occured every nine days, and others in which 
they occurred but once in three or four weeks, or as many or more 
months. Each patient involuntarily arranges his own distinct periods, 
and he usually fulfils the contract. 

Prodromal symptoms have been unusual. Now and then a mother 
will state that she can anticipate an attack by some peculiar behavior 
on the part of the child — that he will lose his appetite or that the skin 
over the face will have a greenish or yellowish tint, or that the breath 
will be offensive. 

The symptoms are very characteristic, and occur in no other condi- 
tion. The child, without prodromal signs, has a sharp attack of nau- 
sea and vomiting. The nausea is extreme ; the retching and straining 
at emesis occur at frequent intervals. There is often no elevation of 
the temperature. There may be, however, decided pyrexia early in 
the attack. In Rachford's experience an elevation of temperature is 
the rule in young children. There is marked prostration. The child 
becomes very pale. The eyes are sunken, and the loss in weight is rapid. 
Acetone bodies are present in the urine. Neither food nor water is 
retained. The thirst is extreme. In all there is exaggerated sighing 
respiration, a true air-hunger. The patients beg for water, only to 
vomit it as soon as it is given. The vomited material usually contains 
hydrochloric acid, while in true gastritis free hydrochloric acid is absent 
(Rachf ord) . 

The illness may last but a few hours, with one or two vomiting 
seizures. In the average case the duration is from three to five days. 
My longest case was in a boy of three years who vomited persistently for 
thirteen days. In some cases the vomiting is sufficiently severe to pro- 
duce hematemesis. A girl of eight years during an attack vomited such 
large amounts of blood that it was necessary to keep her under the in- 
fluence of morphin given hypodermatically. 

The Breath, — During the attack the breath usually has the charac- 
teristic odor of acetone. This is a sweetish odor, not unlike that of 
chloroform.. I have had observant mothers, in describing the child's 
symptoms, refer to this sign without suggestion on my part. An exami- 
nation of the organs and the secretions fails to show anything abnormal 
excepting the presence of acetone, diacetic acid, and oxybutyric acid in 
the urine, as described by Edsall. 

In a mild or moderately severe case the vomiting stops abruptly and 
the child asks for food and retains it, providing reasonably simple food 
is given. In a few days he has made up the loss in nutrition and is as 
well as ever. 

In more severe attacks the child may require several days to regain 
his usual health and vigor. The resumption of the feeding will neces- 
sitate considerable care. 



ACIDOSIS 717 

Differential Diagnosis. — A first attack of cyclic vomiting may be 
confused with meningitis, acute indigestion, or the vomiting in acute 
nephritis, appendicitis, or intestinal obstruction. In the event of an 
abrupt onset in a first attack a diagnosis may not be made for a day 
or two. The differentiation laid down in some of the books is not 
dependable. 

Thus the vomiting which occurs as the earliest symptom of 
tuberculous meningitis may be clinically identical with that of cylic 
vomiting, and only by the appearance of other signs of meningitis or 
through lumbar puncture is the differentiation possible. 

In acute indigestion there is a brief period of fever and one or two 
vomiting seizures, after which the case is well. In acute nephritis an 
examination of the urine readily settles the diagnosis. In appendicitis 
there is pain and spasticity and the vomiting is not continuous ; in 
cyclic vomiting the abdomen is relaxed, soft, and not tender. Intesti- 
nal obstruction is an affection of infancy; cyclic vomiting rarely occurs 
before the second year, and usually not until after the third year. In in- 
testinal obstruction, moreover, there is abdominal distention and the 
passage of bloody mucus, due to intussusception. 

Prognosis. — The prognosis is usually good not only as regards life, 
but as regards the continuation of the attacks. I have seen six fatal 
cases. 

Treatment. — Treatment in the Interval. — In describing the manage- 
ment of children who show the rheumatic complex, the influence of the 
intense carbohydrates and fat was referred to. In the cyclic vomiting 
cases the precaution of witholding these substances from the diet is one 
of the most necessary features of the interval management. Different 
authors refer to the fact that the use of milk in some children is produc- 
tive of attacks. It is the fat content of the milk that produces the at- 
tack. These patients may take fat-free milk and buttermilk without 
inconvenience. The diet prescribed for the cyclic vomiting case is 
that laid down on p. 710. 

Milk-fat, sugar, and egg-yolks are forbidden. Red meat may be 
given only in small amounts. 

Medication. — For a child from three to ten years of age from 9 to 12 
grains of wintergreen, salicylate of soda, or aspirin are to be given after 
meals daily in divided doses, for five days out of fifteen. During the 
ten days of rest from the salicylates 10 grains of bicarbonate of soda 
should be given twice daily after meals. This method of treatment 
must be continued for months. If the salicylate of soda interferes with 
digestion or with the appetite, aspirin in equal dosage may be substi- 
tuted. Under this method of treatment in cases in which attacks had 
been occurring every month or six weeks the intervals have been in- 
creased to six months or a year, and in many cases the attacks have 
entirely ceased. Spasmodic treatment is of little value ; only persistent 
treatment is effective, and there must be confidence and cooperation 
on the part of the family or any treatment will fail. 

An important requirement in the management is that the patient 



718 THE PRACTICE OF PEDIATRICS 

live a normal child's life. There should be a suitable rest period after 
the midday meal. Three meals are to be given daily, and there must 
be one free bowel evacuation daily without the habitual use of enemata. 
A free green vegetable diet with stewed fruit will do much to accom- 
plish this. (See Constipation, p. 236.) 

Treatment of the Acute Attack. — All food should be withheld. Hot 
bicarbonate of soda water, 10 grains in 3 to 4 ounces of water, should be 
given every hour if possible. If it is vomited, one teaspoonful of the 
solution is to be given at a time. If this or plain water is ejected, the 
stomach must be allowed to rest. Medication other than the bicar- 
bonate of soda should not be attempted. After twenty-four hours, 
with a continuation of the vomiting, a colon flushing (p. 793) with 8 
ounces of warm water containing 2 drams of bicarbonate of soda may 
be employed. This should be repeated at six- to eight-hour intervals. 
It is astonishing to note how much of this solution will be taken up if 
the tube is introduced well into the colon. 

Repeatedly I have known patients to retain two pints a day. The 
procedure supphes fluid, relieves thirst, and prevents prostration and 
loss in weight. At the same time the bicarbonate of soda furnishes the 
best antidote to the acid intoxication that exists. If the colonic medi- 
cation is not well retained, it should be used but twice daily, so as not to 
establish an intolerance. Discretion must be used in giving food. 
Some children will have a disgust for all foods, and others will be a& 
hungry as they are thirsty. This, however, is unusual. I have known 
these children to retain twice-baked bread and unsweetened zwieback 
when nothing else could be kept down. Further, when the vomiting 
ceases and the child is on the borderland of convalescence, some one of 
the dried bread-stuffs often answers better than does a fluid diet. In a 
general way, however, a diet of broth, gruel, skimmed milk, and dried 
bread is best for the first few days following an attack. 

If the cases prove resistant and but little of the bicarbonate is re- 
tained, a 2 per cent, solution of the chemically pure drug may be given 
intravenously — from 60 to 80 grams may be introduced in this way. 
The solution may be used plain or in combination with 4 per cent, 
chemically pure dextrose. Hypodermoclysis gives another means of 
using the chemically pure drug alone or in combination with dextrose. 
A 4 per cent, solution of the bicarbonate and dextrose may be used 
in this way. Whether the intravenous or hypodermoclysis method is 
selected, the procedure may be repeated in twelve hours. 

In a recent case of severe acidosis seen with Dr. Mosher, of 
Brooklyn, a fatal outcome seemed imminent. Bicarbonate of soda 
freely administered and two transfusions of bicarbonate of soda with 
four per cent, dextrose, given intravenously failed to produce the 
slightest improvement. In desperation transfusion of human blood 
was decided upon and six ounces of citrated blood was given. The 
improvement following the use of human blood was most remarkable. 
The hyperpnea ceased, the pulse improved and the entire expression 
of the child changed in a very few hours. The boy made a complete 



CYCLIC DIAKRHEA 719 

recovery, all traces of acidosis disappearing within five days after the 
transfusion. 

CYCLIC DLARRHEA 

Excess of sugars and fat in the diet of children of the so-called 

lithemic type may produce characteristic gastro-enteric effects entirely 

. independent of intestinal and stomachic conditions. Patients of this 

; type represent those who possess a poor capacity for the metabolism of 

these substances. 

Cases of this kind are not at all unusual, and are usually attributed 
to errors in diet, to fatigue, to overexcitement or nervousness. 

Symptoms. — There may be a prodromal period of a few days, with 
foul breath, coated tongue, languor, and loss of appetite. More often 
the onset is sudden and without warning. There is sudden high 
fever, headache, vomiting, diarrhea, muscle soreness, and, rarely, 
delirium. Abdominal pain maybe present, colicky in character. The 
fever rarely lasts longer than two or three days — often not longer than 
one day. The gastro-intestinal manifestation of the toxemia may per- 
sist for a shorter or longer time. Some children will have one or two 
vomiting seizures ; others none. The intestines, however, are much dis- 
turbed. Loose watery stools are frequent, and defecation is attended 
with considerable pain and tenesmus. After an indefinite period of 
time — usually one to three days — the symptoms abruptly subside, and 
the child becomes hungry and begs for more food than is good for him. 
Usually after such an attack the child feels unusually well, and no 
evidence of the seizure remains. In the course of a few weeks the 
identical process is repeated, although the mother volunteers the infor- 
mation that the child has been carefully fed and that the attacks can- 
not be attributed to indiscretion in diet. Occasionally such cases are 
associated with cyclic vomiting. 

Illustrative Case. — A boy six years of age almost always — such was the history 
— began the cyclic vomiting attack with the symptoms as described. Vomiting 
ordinarily did not begin until the fever and the urgent intestinal symptoms had 
subsided. 

The attacks are quite apt to be followed by constipation. These 
gastro-intestinal crises become as distinctly periodic as those of cyclic 
vomiting and spasmodic bronchitis. I have treated a large number of 
these patients who have been brought solely because of the periodic 
attacks which are referred to by the mother or nurse as '^ indigestion," 
"gastritis," or '^ biliousness." 

If the attacks are frequent, there will be the signs of malnutrition. 
Usually the patient has resistance of a low order and is apt to be nerv- 
ous and pale. The muscles are flabby. The tongue may be habitu- 
ally coated. The child is chronically tired, ''or never quite well." 
This description obtains in the most severe cases. Children, however, 
who undergo the periodic attacks at intervals of several weeks suffer 
but temporary inconvenience. The acetone breath has been present 
during the attack in a few of my cases ; its occurrence is the exception. 



720 THE PRACTICE OF PEDIATRICS 

Illustrative Cases. — Case 1. — A girl, three years of age, of decidedly gouty ante- 
cedents in both parents, had, for the eighteen months previous to examination, 
attacks of "indigestion" every six weeks. There was no vomiting. The tem- 
perature rarely rose above 103°F. There was pronounced diarrhea with little 
mucus. At each attack she had been given castor oil and a reduced diet, and was 
well in four or five days. Between the attacks she was fairly well, excepting that 
the tongue was never clean and there was a persistent low-grade eczema on the 
neck and upper portion of the chest, which had resisted the treatment of different 
dermatologists. The child had been fed with reasonable care under medical 
direction. There had been no gain in weight during the year. 

She was given a mixed diet of meat, poultry, fish, green vegetables, and cereals. 
One pint of skimmed milk or fat-free buttermilk was allowed daily. Sugar of every 
kind was prohibited. Raw fruit was not permitted. Ten grains of bicarbonate of 
soda were given daily for several weeks. During the twenty-one months of treat- 
ment there has been no suggestion of the former trouble. 

Case 2. — A boy six years of age had repeated attacks of diarrhea lasting from 
two to ten days. The majority of the attacks occurred during the warmer months, 
but there were also three or four during the winter. There was fever, rarely 
higher than 102°F., and rarely vomiting. Dietetic restrictions as regards sugar 
and fat were carried out, and skimmed milk in small amount was allowed during 
the next three months, — July, August, and September, — a period during which he 
had never before been well. He now remained perfectly well, and during this 
time gained 1% pounds in weight. There has been no repetition of the attacks. 

I could give many histories of cases in which the periodic intestinal 
crises were relieved by the withdrawal of fat and sugar from the diet, 
and by the free use of bicarbonate of soda for protracted periods. 
Starches appear to exert no influence on the condition. Sugar that is 
manufactured by the organism exerts no unfavorable influence. 

Treatment. — As indicated, the treatment consists in withdrawing 
fat and sugar largely from the diet, and in the use of bicarbonate of 
soda. If constipation is present, I usually give 30 grains daily with 
sufficient aromatic cascara to keep the bowels active. Stewed fruit 
and cereals are usually readily taken without sugar. If necessary, 
small amounts of saccharin may be used for sweetening. Eating be- 
tween meals is forbidden, and the child is made to take an after-dinner 
rest of one and one-half hours. Stress of all kind is avoided. 



PERIODIC FEVER 

Febrile cases somewhat resembling the above are of unusual occur- 
rence. The clinical condition is that of periodic fever without another 
symptom. 

Illustrative Cases. — Case 1. — The temperature in one of my cases, aged four 
years, ranged from 102° to 103. 5°F. and lasted four to six days. This child came 
to me because of the periodic elevation of temperature which could not be ac- 
counted for. During his third year there were six of these temperature periods. 
In the fourth year there were four, all during January, February, and March. 
There was no gastro-intestinal association and no clinical evidence of disease to 
account for the temperature periods. The mother stated that "the breath smelled 
like chloroform" during the attacks. An exhaustive examination failed to detect 
anything wrong with the child other than a persistent erythema at the angle of the 
mouth on the right side. The patient was given a diet free from fat and sugar. 
Thirty grains of bicarbonate of soda were given daily. Two years have elapsed 
without a return of the temperature period. 

Case 2. — In the case of another boy, aged six years, the temperature period 
persisted two to five days, and the range was 100° to 104°F. During the attack the 



RHEUMATIC FEVER (aCUTE RHEUMATISM) 721 

tongue was coated and the patient complained of being very tired. The attacks 
appeared without warning and disappeared without other evidences of illness than 
the fever. There was no objective gastro-intestinal disturbance. In one year 
there were five temperature periods; during the next year, three. 

In neither of these cases was there another sign of trouble than the 
recurring temperature; the children had been treated and examined 
repeately with an idea to determine the cause. 

In all I have had six examples of this fever phenomenon. All the 
patients were relieved promptly by removing sugar and cow's-milk fat 
from the diet, and by the interval use of bicarbonate of soda. 



RHEUMATIC FEVER (ACUTE RHEUMATISM) 

Acute rheumatism is a rare disease in young children. Conditions 
described as rheumatism in infants and children under two years are 
usually scurvy or infectious peri-arthritis. The latter is not at all un- 
usual, and the possibilities of scurvy are always with us. Among 1027 
cases of rheumatism, Still saw none under two years of age. My own 
cases have all been in children after the third year. The majority of 
the cases occur between the fifth and ninth years. 

It is a mistake to designate rheumatic fever as "acute articular 
rheumatism/' as we see many cases in which the joint symptoms play a 
slight part, or no part at all, the heart bearing the brunt of the attack. 
Repeatedly, endocarditis or pericarditis has been the main manifesta- 
tion of the disease. 

Illustrative Cases. — Case 1. — A boy came to the out-patient service at the 
Babies' Hospital because of sore throat and a temperature of 101°F. There was a 
very mild tonsillitis, and for one night there had been pain in the left knee. An 
examination of the heart showed an extensive endocarditis involving both the 
aortic and mitral valves. 

Case 2. — A girl, four years old, a subject to periodic colds and asthmatic 
bronchitis, had a mild seizure of this nature, requiring that she remain in bed for a 
few days. While examining the lungs I detected a soft systolic murmur. Three 
days later pain and swelling appeared in a knee-joint. A polyarthritis followed, 
involving in all nine joints. In this child the heart involvement preceded the joint 
symptoms several days. 

It is not at all unusual to see endocarditis in the offspring of the 
rheumatic, without the previous existence of a painful joint. These 
cases, however, will afford the history of chorea or recurrent spasmodic 
bronchitis, frequent anginas, periodic gastric or intestinal crises, or 
growing pains. In fact, endocarditis is far more often the manifesta- 
tion of acute rheumatism than is inflammation of the joints. 

On the other hand, many cases are seen in which the heart remains 
free, with the joint involvement of a most urgent nature. 

Etiology. — That acute rheumatism is a manifestation of an infecting 
agent or agencies the majority of the profession are agreed. It will 
probably be demonstrated that more than one infecting agent may 
cause acute rheumatism in a child predisposed in the manner that I 
have attempted to describe in the previous chapter. Perhaps it will 
46 



722 THE PRACTICE OF PEDIATRICS 

be proved that both bacterial and other toxic agents may cause the 
disease. 

Symptoms. — (For Endocarditis, see p. 379.) Like all diseases of an 
infectious origin, acute rheumatism may be so mild as to escape notice, 
or it may be most severe. In the joint type the first symptom is pain 
in the joint; this may be very slight, or it may be most intense — so in- 
tense that the bed-clothing may not touch the parts without increasing 
the pain. Between these two extremes there are all degrees of involve- 
ment. There may be neither swelling nor redness, or the swelling may 
be extreme, with marked redness, the part being twice as large as its 
uninvolved fellow. One joint or several may be affected. The pain 
and swelling usually begin in one, and subsequently affect others. The 
first joint to become inflamed is usually the first one in which the in- 
flammation subsides. 

The duration of the attack is also subject to much variation — it may 
last but a few days, or it may last for six weeks or longer. A case of 
average severity rarely lasts longer than two to three weeks. 

There may be no temperature, or it may range from 103° to 105°F., 
depending entirely upon the severity of the infection. 

Prognosis. — The prognosis for the immediate attack in articular 
rheumatism is good. All cases recover if there is no heart involvement. 
When there has been one attack, however, there is great liability of 
another, and parents should be made to understand this feature of the 
disease. In the second seizure the heart may be the part attacked. 

Precautions. — In every case of joint rheumatism the heart should 
be examined daily for evidence of endocarditis and pericarditis. 

Treatment. — General Management. — Rest in bed is an absolute 
necessity even in the milder cases. The diet of the patient may consist 
of milk, junket, gruel, toast, stale bread, weak tea, stewed fruit, and 
orange- juice. Vichy and lemonade may be given to drink. There 
should be one evacuation of the bowels daily. 

Local Measures. — Considerable comfort may be furnished by local 
measures, which will permit the child to sleep, resulting in a much im- 
proved food capacity. The affected joint or joints should be comfort- 
ably supported on a cushion or pillow, and the parts kept well protected 
by cotton-wool or flannel dressings. The U. S. P. lead and opium 
solution which is used to moisten the gauze dressings will aid in reliev- 
ing the pain. The joint should be loosely wrapped in strips of linen 
which have been wet with the warm solution. Over this should be 
placed oiled silk to prevent rapid evaporation, and over all a flannel 
bandage. In the acute cases the dressing should be changed every 
hour until the pain is relieved. This can readily be done without dis- 
turbing the patient. A liniment composed of menthol, 2 drams, tinc- 
ture of opium, lyi ounces, and enough alcohol to make 6 ounces, 
applied on strips of linen and covered with oiled silk, is another local 
application which has been of considerable service in relieving pain. 
The dressing should be renewed every two or three hours as the case 
requires. 



EHEUMATIC FEVER (aCUTE RHEUMATISM) 723 

Drugs. — Various drugs, such as oil of wintergreen, aspirin, and com- 
binations of the alkahs with the saHcylates, have been used in a consid- 
erable number of cases. The most effective internal medication has 
been the bicarbonate in association with the salicylate of soda. The 
salicylate must be given in large doses. Two points, however, are to 
be kept in mind in the use of large doses of salicylate in children : its 
depressing effect upon the heart, and the tendency to produce derange- 
ment of digestion, as evidenced by nausea and vomiting. The salicy- 
late should never be given with the stomach empty. It is given to the 
best advantage after meals, and always in solution. For a child five 
years of age, the following may be prescribed: 

^ Sodii salicylatis 5ij 

Elix. simplicis § iss 

Aquse q. s. ad§iv 

Sig. — One teaspoonful in plain water or in Vichy four times daily 
after meals. 

There are about 24 teaspoonfuls in a 4-ounce bottle. The average 
teaspoonful, as is well known, holds more than one dram. Computing 
24 doses to a 4-ounce mixture, we give this five-year-old patient 20 
grains of salicylate of soda in twenty-four hours. The amount may be 
increased to 30 grains if the condition is serious. Larger doses than 30 
grains for children of this age I do not consider safe, as I have seen such 
doses followed by irregularity of the heart action and cyanosis. The 
average child from eight to ten years of age will take 30 grains daily 
without inconvenience. At the third year I have given from 12 to 15 
grains repeatedly, with most satisfactory results. The bicarbonate of 
soda may be given in combination with the salicylate, but it is best 
given alone in Vichy or carbonic water between meals. To a child 
five years old or under, 20 grains should be given in twenty-four hours. 
For children from seven to ten years of age, 30 to 40 grains daily is 
the amount required. 

The dosage, both of the salicylate and of the bicarbonate of soda, 
should gradually be reduced as the condition of the child improves. 

Later Treatment, — It is my custom never, willingly, to let a child 
who has once had an attack of acute articular rheumatism disappear 
from my observation. As the outcome of repeated attacks, endocar- 
ditis is likely to develop sooner or later. After one attack the parents 
should be advised as to the probablity of a recurrence, and its dangers 
should be pointed out to them. They should be instructed to keep the 
child on a low meat and sugar diet. Sugar is to be given only in suf- 
ficient quantity to make the food palatable. Five days out of every 
fifteen, 10 grains of the salicylate of soda, separately or combined with 
10 grains of bicarbonate, should be given daily. This should be contin- 
ued for six months, when treatment for five days out of each month will 
suflB.ce. In some cases I have continued this method indefinitely. 

In all cases of acute articular rheumatism in children the tonsils 
and adenoids should be thoroughly investigated and their removal ad- 



724 THE PRACTICE OF PEDIATRICS 

vised if found diseased. Foci of infection have also been found at 
the root of the teeth, therefore an x-ray examination of the teeth 
should always be made. 



RHEUMATOID ARTHRITIS; ARTHRITIS DEFORMANS; 
STILL'S DISEASE 

Under the above headings may be noted those forms of chronic 
arthritis which occur independently of ordinary pyogenic infection, 
gonorrhea, syphilis, tuberculosis, rheumatism, and rachitis. Attempts 
at exact differentiation of the arthritides of this class rest in the main 
upon varying clinical manifestations which may or may not represent 
separate and distinct disease processes. In a recent reference to this 
subject Rachford* has emphasized three types of ^'rheumatoid ar- 
thritis" — (1) Chronic arthritis with hypertrophic changes predominant; 
(2) chronic arthritis with atrophy predominant; (3) Still's disease. 

The condition last named is sufficiently striking to require special 
attention, and the points emphasized by Still are here mentioned. 

StilPs Disease. — The specific etiology is unknown. The disease is 
quite possibly of bacterial origin. Females are apparently slightly 
predisposed. Children are rarely susceptible after the sixth year. 

The morbid anatomic changes comprise thickening and vasculariza- 
tion of synovial membranes, capsules, and ligaments of the affected 
joints, and, in advanced cases, moderate atrophic changes in the carti- 
lage, with perhaps the formation of adhesions. Effusion is not an es- 
sential part of the process. Considerable enlargment of the lymphatic 
glands and spleen is a constant feature. 

Symptoms. — The onset is usually gradual, but may be acute, with 
fever and chills. Primary stiffness in one or more joints is succeeded 
by progressive joint enlargement without bony involvement, ankylosis, 
or suppuration. The knees, wrists, cervical spine, fingers, ankles, and 
toes may be affected. Active and passive movements are restricted, 
and eventually atrophy and contracture of muscles may occur, without, 
however, impairment of electric reactions. The lymphatic glands are 
enlarged, particulary those related to the affected joints. The edge 
of the spleen may usually be found below the costal margin. The 
blood shows a moderate anemia and occasionally a leukocytosis. 

Still's disease is to be distinguished from rickets, syphilis, the 
various forms of muscular atrophy, and caries of the cervical 
vertebrae. 

The prognosis is not favorable. The disease is not directly 
fatal, but its effects are crippling. Koplik reports a recovery. 

The treatment of rheumatoid arthritis is largely symptomatic. An 
even climate, free from excess of moisture, is desirable. Anemia and 
malnutrition are to be combated in the usual manner. Massage and 
suitable applications may influence the local conditions favorably. In 

*" Diseases of Children," B. K. Rachford. 



CHONDRODYSTROPHIA (ACHONDROPLASIA) 725 

view of the possible influence of latent foci of infection upon the devel- 
opment of the disease, oral sepsis and intestinal putrefaction, espe- 
cially, must be prevented. Pituitary extract is of possible value. 



CHONDRODYSTROPHIA ( ACHONDROPLASIA) 

Achondroplasia is a disease of fetal life characterized chiefly by de- 
fective development of the long bones. 

The terms applied to this disease constitute a long list. Some of 
these are ''fetal rickets," ''micromelia," ''chondromalacia," "fetal 
chondritis," and " chondrodystrophia foetalis." 

Emerson, writing in Osier's "Modern Medicine," cites many ex- 
amples from Egyptian, Grecian, and medieval art, which go to prove 
the antiquity of this disease. He further states that of all dwarfs, 
those with this affection have been most popular in the positions of 
court clowns and jesters. The condition has long been confused with 
rickets, cretinism, and certain types of syphilis. Parrot first made 
clear the pathologic distinctions in 1878, and Porak gave a very full 
account of the subject in 1899. 

Etiology. — Heredity is an influential but not apparently an un- 
failing factor. In many instances there is no family history of a sig- 
nificant character. Emerson suggests that achondroplasia and rick- 
ets may be related, in spite of the usual variance in their manifestations 
and the evidence against the occurrence of so-called intra-uterine 
rickets. By many achondroplasia is thought to be due to defective 
function in one or more of the glands of internal secretion. Syphilis 
is sometimes associated with this affection, but cannot be said to be 
a cause. 

Pathology. — The lesions are localized in the bones, more particu- 
larly the long bones and those of the base of the skull. The epiphyses 
are primarily affected. Here there is always defective formation of 
cartilage, whence the descriptive name, chondrodystrophy. Periosteal 
growth goes on, and, by invading the region which is normally sup- 
plied with bone by the cartilage-cells, impairs still more the cartilag- 
inous formation of bone, interferes with the union of epiphysis and 
diaphysis, and checks the growth of the bone in length. The irregular 
cooperation of the chondral and periosteal tissues in the development 
and growth of the bones similarly explains the actual deformities in 
their shape. Most of the cases belong to the type known as hypoplastic. 
The epiphyses are normal in size, and there is impaired growth of the 
cartilage-cells. In the hyperplastic form, however, which is rare, the 
growth of cartilage exceeds the normal, and the epiphyses are enlarged. 
In chondrodystrophia foetalis malacia the epiphyses are soft, due to 
decrease in the consistence of the intercellular matrix. 

Symptoms. — The dwarf presents a peculiar appearance; to such a 
degree is this true that he is often a source of revenue. These indi- 
viduals have normal intelligence, and being quick to turn their physical 
defects into pecuniary gain, they may often be seen on the vaudeville 



726 



THE PRACTICE OF PEDIATRICS 




or comic opera stage doing minor roles as foils to men of large stature. 
The trunk is of normal size, while the extremities are very short. 
The head may be involved. It may be very large, showing a dome- 
shaped contour, not unlike that of hydrocephalus. The features may 
be large, with broad nose and prominent cheek-bones. The forehead 
is usually wide, with the eyes set widely apart, due to the broad root 
of the nose. The facial appearance, as described, while usually pres- 
ent, is not necessarily a part of the pic- 
r 1 ture. I have seen several cases in which 

the facial configuration differed in no 
wise from that of the general average 
of humanity, as shown by Fig. 105. 
The muscles of the extremities, while 
short, are very large and strong, and 
these little people oftentimes possess 
prodigious strength in lifting or carry- 
ing heavy objects. 

The appearance of the child is 
characteristic, further, in that the hips 
are very heavy and broad, this ap- 
pearance being produced in part by 
the peculiar articulation of the thigh 
with the trunk. The articulation takes 
place at almost a right angle, due to the 
change in the contour of the neck of 
the femur. There is marked lordosis, 
the lumbar curve being markedly ex- 
aggerated. (See Fig. 105.) This causes 
a tilting and narrowing of the antero- 
posterior diameter of the pelvis, which 
in girls may be a factor influencing 
normal childbirth in later life. 

The hands are usually square, and 
the fingers very short. The feet take 
on the same appearance being short 
and thick. 
Diagnosis. — Chondrodystrophia may be confused with rachitis or 
cretinism early in the first few months of life. Rachitis and chondro- 
dystrophia have been confused, usually for the reason that chondro- 
dystrophia is such a rare condition that it was not known to exist and 
consequently was not suspected. 

I The very short, thick extremities, together with the facial charac- 
teristics and normal mentality, are sufficient for a differentiation. 
Further, the changes due to rachitis are of gradual development, and 
are never present at birth. In chondrodystrophia the child, when 
very young, shows an appearance as characteristic as when he is two 
years of age or older. 

Cretins are very degenerate mentally. They are slow and stupid, 




Fig. 105. — Chondrodystrophia. 
Lateral view. 



CRETINISM 



727 



exhibit no mental response, and show but Uttle irritation upon manipu- 
lation. In chondrodystrophia the mental condition is usually nor- 
mal; at least those with chondrodystrophia cannot be placed in the 
class with the mentally defective. 

Prognosis. — I disagree with those who claim a high infant mortality 
in chondrodystrophia. I fail, however, to see that mortahty statistics, 
in view of the very few cases that exist, can be of value. 

Physical Health. — I have had but five under my professional direc- 
tion as infants, and all 
are well and thriving in 
their own way. One, now 
about six years old, is the 
offspring of a mother who 
is a chondrodystrophiac. 
Both men and women 
dwarfs are fertile. Giving 
birth to children is often 
a dangerous procedure, 
because of the antero- 
pK)sterior narrowing at the 
pelvic brim and a tilting 
of the pelvis. 

Treatment. — Treat- 
ment is of no avail, no 
means having been dis- 
covered to induce growth. 

CRETINISM ( INFANTILE 

MYXEDEMA; CRETINOID 

IDIOCY) 

Cretinism was de- 
scribed by Paracelsus 
early in the seventeenth 
century. Until the mid- 
dle of the nineteenth cen- 
tury, however, the disease 
was only imperfectly 
differentiated. Fagge de- 
scribed the sporadic form 
in 1871, and in 1873 Gull emphasized the similarity of this disease to 
adult myxedema. Some years later, following the experiments con- 
ducted by Victor Horsley, a commission appointed by the Clinical 
Society of London reported that myxedema and cachexia strumi- 
priva were identical, that sporadic cretinism was myxedema occur- 
ring in childhood, and that endemic cretinism was closely allied 
to myxedema. The successful work of Schiff, von Eiselsberg, and 
Horsley in the artificial grafting of thyroid gland induced George R. 
Murray in 1891, to employ hypodermic injections of an extract of the 




Fig . 1 06 . — Chondrodystrophia . 



728 



THE PRACTICE OF PEDIATRICS 



gland in the treatment of myxedema. Howitz, Fox, and MacKenzie 
obtained equally good results from thyroid medication by mouth. 
The wonderful success of this form of organotherapy during the five 
years following its initial use led Osier to write: ''Not the magic wand 
of Prospero, or the brave kiss of the daughter of Hippocrates, ever 
effected such a change.'^ 

Cretins usually do not come under observation before the sixth 
month. Not much is expected of a baby of a few months old, and if he 
is very quiet and slow at noticing his surroundings, the fact is attri- 
buted to his tender age or to his being a good baby. When, however, 

at the fifth, sixth, or seventh month, he 
fails to show the usual response for his 
age, medical attention is called to the 
condition. My youngest patient was 
three months old. When first seen, the 
patients have usually been from six to 
eighteen months old. My oldest case 
was four years of age. A cretin girl 
was three years old (Fig. 108) and 
weighed 15 pounds, 3 ounces. 

Etiology. — It is undoubtedly estab- 
lished that the ''condition" termed 
cretinism depends upon the absence of 
the thyroid secretion, and that the 
various degrees of cretinoid idiocy hinge 
upon the partial or complete absence of 
the thyroid gland. Cretinism varies in 
degree and in the time of its develop- 
ment. In typical cases (Fig. 107) there 
is complete absence of the thyroid gland ; 
in others, showing the disease in less 
severe form, an impaired thyroid is 
found. 

Pathology .^ — In 16 autopsies collected 
by Fletcher Beach the thyroid was absent 
in 14. In 100 cases of Curling, Fagge, 
and Iphophon the gland was found 
absent in 25; in the other 75, various connective-tissue and colloidal 
changes were observed. In endemic cretinism ("not found in this 
country," Osier) alterations are found in the thyroid consisting of 
partial or complete degeneration, which may be either atrophic or 
goitrous in its inception; or, as Getzowa has described, cases are 
found in which atrophic areas and goitrous degenerated nodules al- 
ternate in the same gland. In sporadic cretinism there is usually con- 
genital absence, while in infantile myxedema due to acquired loss or 
perversion of thyroid function in the early years of life the symptoms 
vary according to the amount of functional disturbance of the gland. 
According to Kocher, in myxedema there is always abolition of the 




Fig. 107. — Cretin four years 
old. Never received thyroid 
treatment. 



CRETINISM 



729 




Fig. 108.- 



-Cretin three j^ears old. 
treatment. 



Before 



function of the gland, which at autopsy is never normal. In the ma- 
jority of cases it is re- 
placed by a band of tis- 
sue (Virchow); at other 
times, by adipose tissue 
without a trace of the 
thyroid artery (Stilling). 
Ord was the first 
man to examine micro- 
scopically the thyroid in 
a case of myxedema. In 
the majority of instances 
neither Virchow nor 
Horsley, in their exten- 
sive observations, was 
able to find vestiges of 
acini or thyroid cells- — 
bunches of connective 
tissue occupying the re- 
gion of the gland. Still- 
ing made similar inves- 
tigations, and found the 
thyroid artery missing, while Langhans states the changes to be 
those of an interstitial inflammation, with embryonal cell infiltration; 
I ^^^^ — 1 in fact, an inflammation 

comparable to cirrhosis of 
the liver. By degrees the 
tissues become sclerosed 
and the vessels undergo 
endarteritis obliterans, 
while the acini become 
atrophied and disappear. 
As these changes progress 
the function of the gland 
diminishes. 

The parathyroids are 
normal. The hypophysis 
cerebri is atrophied in some 
cases and hypertrophied in 
others. The brain shows 
no gross abnormality. The 
genitals are infantile in 
character. The skin is 
thick, with a scanty de- 
velopment of hair and 
sweat-glands. The adipose tissue is very abundant, both beneath the 
skin and in the omentum; often there are pads of fat above the clav- 







Fig. 109. 



Cretin after thirty-four days' 
thvroid treatment. 



730 THE PRACTICE OF PEDIATRICS 

icles. The entire osseous system shows a lack of development and 
ossification. 

Symptoms. — When very young — under one year of age — the chil- 
dren are dull and mentally inactive; they are passive, and show little 
or no interest in their surroundings ; they resist manipulations, such as 
dressing, bathing, and physical examination, but little, if at all. The 
extremities usually are cool, oftentimes slightly moist. 

The general appearance is characteristic (see Fig. 107), regardless 
of the child's age. The hair is dry and coarse; the face is broad; the 
nose wide and flat, and the lips are broad and thick. The tongue pro- 
trudes between the lips. The tissues have a doughy, edematous 
appearance and feel boggy to the touch, but do not pit. The forehead 
is low. The abdomen is usually large, and there is almost invariably 
an umbilical hernia. The neck is short and thick. The hands and 
feet are large; the fingers and toes are short and thick. The patients 
are very short in stature. (The child shown in Fig. 108 was but 26 
inches tall when three years of age.) The fontanel is widely open. 
Dentition is greatly delayed. The temperature is usually subnormal. 

The cretin walks late, rarely, if untreated, before the third year. 
Fig. 107 represents a cretin four years old who cannot stand without 
assistance. He is 313-^ inches tall. Mentally and physically such 
individuals are slow and inactive. The mental impairment is consid- 
erable, idiocy being the outcome in most of the untreated cases. 

Acquired Cretinism. — In some, early development is fairly normal 
and the unmistakable signs do not appear until the child is several 
months of age. 

Illustrative Case. — A girl, three and one-half years of age, with delayed or 
acquired cretinism, was brought to me from another city. The child was perfectly 
normal until the third year of age. She then became inactive and took no interest 
in her surroundings. The hair became coarse and dry, the extremities cool. The 
expression was dull and listless. The child presented a general edematous ap- 
pearance. The diagnosis of cretinism was proved by a prompt response to thyroid 
medication. 

Diagnosis. — The diagnosis in typical cases is without difficulty. 
The nature of the trouble is stamped on every feature. The slow 
mental responses and the dwarfed, edematous extremities furnish a 
picture that is simulated by but one other condition, and this is 
Mongolian idiocy. In the Mongolian the round face, the elliptic eye, 
and the absence of shortening in the long bones are sufficient to estab- 
lish a differentiation. 

Prognosis. — The prognosis for a complete recovery is good if the 
case is discovered before the eighth month. I have several patients 
under treatment who are apparently normal children when judged by 
school and family standards. No one knows that these children are 
cretins. In those in whom treatment is not begun until after the first 
year — surely after the eighteenth month — the chances of normal men- 
tality are lessened. The earlier the case comes under treatment, the 
better the possibilities for the patient, both physically and mentally. 



CRETINISM 731 

Treatment. — The Thyroid Treatment. — The specific treatment is 
the thyroid treatment. The most pronouncedly beneficial results of 
this treatment are noticed when it is brought into use early in life. 
The diagnosis of cretinism is rarely made before the fifth or sixth 
month, often much later, for the reason that the case does not hap- 
pen to come under the observation of those competent to make the 
diagnosis. 

Illustrative Cases. — In two cases the patients were first seen by me at the fifth 
and the seventh month respectively. Other cases have been treated in institution 
and in private work. The two referred to, however, were seen earUer and almost 
daily for months, consequently there was an excellent opportunity for observing 
the effects of the thyroid administration. The desiccated thyroid extract of 
Parke, Davis & Co. was used. 

A fairly complete history of the progress of one of the cases is as follows : The 
beneficial effects were noticed in three days. The first change for the better was 
observed by the mother, who stated that the child seemed warmer and that less 
bed-clothing was necessary. The next positive change occurred, according to my 
records, on the fifth day of treatment. The child's general condition was very- 
much improved. Her extremities were warmer, her color better, and she com- 




110. — Cretin, aged six months, before beginning thyroid treatment. 



menced to use her arms; but what particularly impressed the mother was that 
less bed-clothing was needed to keep the child warm. At about the seventh day of 
treatment the patient cried vigorously when disturbed for the purpose of changing 
the napkin — something which she had never done before. She had previously 
been stupid and apathetic. The next changes for the better rapidly followed; the 
patient noticed and appeared interested in her mother, and followed the latter 
about the room with her eyes, and while previously the child had rarely used her 
legs and arms except when disturbed, she now began to move them about volun- 
tarily; as the mother expressed it, "The child had acted as though she were under 
the influence of some powerful depressing drug whose effects were gradually 
wearing off." When the child was five and one-half months old, after she had been 
under treatment for sixteen days, receiving )^ grain of thyroid twice daily, she 
smiled for the first time. She cut the first tooth at the ninth month, and walked 
alone at the fourteenth month. She is now taking 5 grains daily, and is apparently 
normal in every respect. She attends school, and is but one grade below the 
average school-child of her age, which means that she is in the same grade with 
other children who are normal. 

When the child in whom treatment was commenced at the seventh month was 
nine months of age, it was found necessary to give 3^ grain three times daily. One 
month later >^ grain was given four times daily. At this time the child could sit up 



732 THE PRACTICE OF PEDIATRICS 

and hold the head erect. The increase in the thyroid extract produced vomiting, 
and the dosage of 3^ grain three times daily was resumed. One year after the com- 
mencement of the treatment, when the patient was nineteen months old, 2 grains 
daily were required. 

In both of these infants the protrusion of the tongue was one of the latest 
symptoms to disappear. 

Dosage, — The increase in the thyroid administration must be deter- 
mined by the condition of the patient. As long as progress is shown in 
more active and normal mentality, with an increase in the growth of the 
long bones and a gradual loss of the typical facial and bodily character- 
istics, it is unwise to increase the dosage of the thyroid. When, how- 
ever, a period arrives when no progress appears to be made, the daily 
dosage should gradually be increased by 3^^ grain. Evidences of 
overdosage are pallor, prostration, perspiration, and indigestion. When 
any of the above signs present themselves, the medication should be 
discontinued for twenty-four hours and then resumed with smaller 
doses. 

My cases have varied considerably as to the amount of thyroid 
required. The dosage used was that taken by those in whom the dis- 
ease was discovered very early in life. The older the patient when the 
thyroid medication is begun, the less marked are the beneficial results. 

Illustrative Cases. — I have a girl five years of age under treatment at the 
present time who came under my care two years ago weighing 15 pounds and 3 
ounces. She made a marvelous improvement under }^ grain of thyroid twice a 
day, which in two weeks was increased to }i grain three times a day. _ This we 
were obliged to decrease because of the prostration and perspiration which it ap- 
peared to occasion. The dosage of }^ grain three times daily could not be used 
until she was four years of age. She is now five years old and requires 1 grain 
three times a day. In this child the most remarkable improvement was noted. 
(See Figs. 108 and 109.) 

The interval of time between the photographs was thirty-four days. Six teeth 
were cut in three weeks after beginning the treatment, and 14 more were cut during 
the next six months. The child made corresponding improvement in every other 
respect. _ _ _ , _ 

Another girl patient, now nine years old, and normal in every respect except 
that her hair is rather coarse, with a tendency to dryness of the scalp, was found to 
require the following amounts of desiccated thyroid at the various ages: 

Six months 13^ grains daily 

One year 3}'^ ** '* 

Two years 5 " " 

Three years 9 *' " 

Four years 8 " " 

This patient both walked and talked at fifteen months. In her case, in order 
to determine what the effects of the withdrawal of the treatment might be, the 
thyroid was discontinued. This was first attempted when she was two and one- 
half years of age. The mother was asked to keep close watch in order to detect 
the slightest difference in the child's behavior. After three days without thyroid 
it was noticed that the child became less active and disinclined to play. She was 
not irritable or cross, but would sit in her little chair the entire day. She had 
previously been very bright, active, and talkative. A few days later she ceased to 
talk voluntarily and answered only when spoken to. After an interval of twelve 
days the thyroid was resumed, and her activity again returned. About one year 
later a similar trial was attempted with similar results, although the duration of the 
test was shorter, as the mother, who was a dispensary patient and had had the 
thyroid furnished her, purchased a bottle of tablets and gave them on her own 
responsibility. The child, when nine years old, was taking 12 grains daily. She 
was a normal, healthy school-girl, alive to all interests of girlhood, and no one out- 
side the family circle in the village where she resided knew that she was a cretin. 



DWARFS 733 

The thyroid must be continued during the Ufe-time of the patient ; 
when it is discontinued, the mental processes soon begin to lag. In- 
difference to surroundings and aversion to physical effort soon appear, 
all to disappear again when the thyroid is resumed. 



DWARFS 

In dwarfism there is an underdevelopment of allparts of the body 
both of the skeleton and of the soft parts. It cannot be doubted that 
this condition is purely dependent upon a congenital tendency, but the 
same effects can be produced, at least in so far as the inhibition of growth 
is concerned, by harmful influences exerted during the period of devel- 
opment and growth. Thus one cannot always tell with certainty 
whether an abnormal bodily growth is dependent upon a congenital 
tendency or upon pathologic influences during the period of growth. 

A true dwarf is a person of small stature, not deformed, whose de- 
velopment has proceeded symmetrically and at a normal rate (except 
as regards extent) in comparison with other races, families of the same 
race, or members of the same family. According to Sainton, a dwarf 
should not exceed 59 inches (1.5 meters). His best illustration is the 
race of pigmies in Central Africa, whose height is about four feet. In 
them the dwarfing is not due to any pathologic process. Sexual devel- 
opment, epiphyseal union, and ossification take place at the usual 
time. 

Symptomatic infantilism or dwarfism is a term used for dwarfism 
associated with delayed ossification, dentition, and sexual development. 
It is usually the result of some illness or disturbance of nutrition which 
interferes with growth. In these cases the body is undeveloped, weak, 
and slender. Usually there is both mental and physical delay. The 
common causes are general dystrophies, congenital heart disease, 
tuberculosis, and syphilis. This condition may also be due to a defi- 
ciency of the internal secretions, rickets, spinal caries, and lateral 
curvature. Another type which is described by Loraine is due to a 
congenital nondevelopment of the arteries (an angioplasia). 

According to Hastings Gilford, true dwarfism (ateliosis) is divided 
into two groups — asexual and sexual. The subjects are well propor- 
tioned, with childish faces and intelligence, irregular and backward 
teeth, small bones and muscles, and an imperfect sexual system. In the 
first type the whole body is affected, but the sexual organs are the most 
backward. The arrest in development may occur at any time of life, 
and hence the subjects are not dwarfs. There is usually but one in a 
family. The body proportions, contour, and intelligence are those of a 
child, and the testes are commonly undescended. In sexual ateliosis 
the development is always delayed until puberty. The epiphyses then 
unite, and the sexual organs mature normally. The child resembles a 
miniature adult, but retains the physiognomy, proportions, and stature 
of a child. These patients differ from physiologic dwarfs (pigmies) 
in the retention of many childish characteristics. Sexual ateliosis is 



734 THE PRACTICE OF PEDIATRICS 

frequently hereditary, and some of the affected individuals may have 
children with dwarfism of the asexual type, thus suggesting a relation- 
ship between the two. 

Cretinism and chondrodystrophy are treated under separate head- 
ings. The cases are often classed with those of dwarfs, but do not rep- 
resent true dwarfism, as the subjects are dwarfed in stature only, and 
in the cretin growth takes place under thyroid therapy if the case is seen 
early in life. 

DIABETES INSIPIDUS 

Persistent polyuria — diabetes insipidus — is rare in children. The 
disease is characterized by extreme thirst and the passage of large 
quantities of pale urine, the condition continuing for months and years. 

Temporary or transient polyuria is of occasional occurrence. There 
is unusual thirst and the passage of abnormally large amounts of urine , 
a condition continuing for a few days or a week or two. 

Etiology. — The cause of persistent polyuria is but little understood. 
Cases are on record in which the condition has seemed to be closely 
associated with brain tumors, hydrocephalus, and trauma. But three 
cases ha\e come under my observation. In these three no cause could 
be discovered. Temporary or transient polyuria, under my observe- 
tion, has always existed in nervous girls of hysteric tendencies. It is 
most apt to develop near the close of the school year, when the child 
is considerably reduced or somewhat excited in anticipation of under- 
going examinations. 

Diagnosis. — Polyuria is to be differentiated from diabetes mellitus 
by examination of the urine. The absence of sugar determines the 
diagnosis. 

Symptoms. — In both the mild and severe cases there are thirst and 
the passage of large amounts of urine, the amount of urine ranging from 
50 to 100 ounces daily. The specific gravity is low — 1002 to 1010, 
The amount of urea and uric acid excreted varies but little from the 
normal. 

In two of the cases of true diabetes insipidus there were a secondary 
anemia and a moderate degree of malnutrition. One patient was much 
undersized, and at the age of five and one-half years weighed 303^ 
pounds and was 373^^ inches high. That the lack of development was 
due to the polyuria, however, is extremely doubtful. 

Treatment. — ^In the cases of functional nervous origin the cure takes 
place by a change of environment . When the nervous stress is removed ,, 
the symptoms subside. 

In the true cases no means of treatment have been of avail in my 
hands. In the case of the boy referred to, various methods of manage- 
ment have been attempted without success. With a diminution of the 
fluids taken there is a corresponding reduction in the output. As soon 
as he is allowed freedom in drinking, the frequency in urination and 
the polyuria return. Drugs have been of no value. 



DIABETES MELLITUS 735 



DIABETES MELLITUS 



True diabetes in children is, fortunately, a comparatively rare 
disease. 

Etiology. — The cause of diabetes mellitus is not known. Heredity 
is supposed to play an important part. In 11 cases in children under 
nine years of age no etiologic factor could be discovered. My youngest 
case seen was nine months of age at death. The disease was known to 
have existed but three weeks. Various theories have been advanced 
from time to time, but we are still as much in the dark as were our med- 
ical forefathers. Heredity is supposed to be a factor. In not one of 
my cases was there a diabetic association of this form. Among adults, 
Hebrews are more liable to the disease than others. Jewish children 
have shown no special tendency thereto. 

Pathogenesis and Morbid Anatomy. — In ^'A Study of the Patho- 
logical Anatomy of the Pancreas in 90 Cases of Diabetes Mellitus" 
published in 1909, R. L. Cecil reviews the work of Opie, von Mering, 
Minkowski, Sauerbeck, and others, and reports that anatomic lesions 
of the pancreas occur in more than seven-eighths of all cases. In the 
cases associated with lesions of this organ the islands of Langerhans 
were constantly involved in changes ranging from sclerosis and hyaline 
degeneration to infiltration with leukocj^es and hypertrophy, while 
in some cases these islands were the only portions of the gland involved. 
In 12 per cent, of the cases investigated no pathologic changes were 
found, although in half of the 12 per cent, the gland was smaller, or the 
number of islands less than normal. Three-fourths of the cases pre- 
senting no lesions occurred in patients under the age of thirty. 

Abt and Strouse have reported two cases of traumatic diabetes 
in children. In one the diabetic symptoms followed a fall on the 
head. In the other the injuries were associated with only a brief 
period of unconsciousness, and the chief lesion was a compound frac- 
ture of the tibia. Both patients developed persistent glycosuria and 
other diabetic symptoms, and responded typically to treatment. 
Other cases might be cited of injuries varying from simple concussion 
to fracture of the skull, with a subsequent glycosuria or even permanent 
diabetes. Langstein records a persistent glycosuria in two young 
infants affected respectiveh' by hydrocephalus and malformation of 
the brain. 

Very recentlj^ the subject of experimental diabetes has been inves- 
tigated by ^lacLeod. He states that dextrose may appear in the urine 
as a result of deficient utilization of this carbohydrate by the tissues, 
because of deficient renal function permitting the escape of sugar nor- 
mally present in the blood,* or because of an increased production of 
dextrose in the liver. To the last of these sources of a hyperglycemia 
he attaches the greatest importance. The hepatic conversion of the 
glycogen into dextrose is shown to be influenced by a reflex mechanism 

* Under normal conditions the blood contains about 0.1 to 0.15 per cent, of 
glucose. 



736 THE PRACTICE OF PEDIATRICS 

operating through the fourth ventricle and the splanchnic nerves. 
That certain drugs and the carbon dioxid present in the blood in 
asphyxia may produce hyperglycemia by their effects on these nerve- 
centers controlling glycogen conversion is considered probable. The 
influence of secretions from such sources as the pancreas, thyroid, and 
adrenals, while probably important, is not yet fully understood. 

The Urine. — The urine is ordinarily increased in amount, clear, 
acid, and of high specific gravity — 1025 to 1050. The amount of 
glucose present varies widely, depending on the character of the diet, 
time of day, and time of meals. During certain periods the sugar 
may be absent. Acetone, diacetic acid, and beta-oxybutyric acid 
may be found, depending on the severity of the disease. The first 
two of these substances are oxidation products of the third, which 
appears only in severe cases. 

Symptoms. — Diabetes mellitus is very constant in its symptoma- 
tology in children. An early and never-failing sign is loss of weight 
without apparent cause. The loss of weight is so pronounced that it is 
often the first symptom to which the attention is called. Thirst is also 
an early symptom. It is of a very urgent nature. The child never 
seems to be satisfied. The thirst is so great that the patient is awak- 
ened by it in the night and demands water. Milk or any fluids will be 
taken, but if a choice is given, water will be selected. Repeatedly 
I have known patients, if allowed, to drink 5 or 6 quarts of water a 
day. 

Frequent urination is always present, large amounts being voided; 
100 ounces in twenty-four hours is not uncommonly excreted by quite 
young children. Enuresis occurs in over half the cases. The skin is 
dry; perspiration rarely occurs even on the hottest days or when the 
body is covered with warm clothing. A light brawny desquamation 
is not infrequently seen. 

The child becomes listless. There is disinclination to play, and the 
interest in childish things flags. 

The appetite is usually voracious, the child not at all particular as 
to the kind of food taken. No matter how carefully the food is selected 
and prepared, the emaciation continues. 

' As the case makes its inevitable progress toward dissolution the 
emaciation progresses and the weakness increases until the patient is 
confined to bed. If an intercurrent disease, such as bronchopneu- 
monia, does not terminate the illness, the child dies from exhaustion 
or acetonemia. 

Diagnosis. — The presence of diabetes is suggested by loss in weight 
and strength, in association with a voracious appetite and inordinate 
thirst and dryness of the skin. An examination of the urine determines 
the diagnosis. The disease may be confused with persistent polyuria 
and with chronic interstitial nephritis. Here again the differentiation 
is made by the urine examination. 

Duration of the Disease. — Few cases live longer than a year. The 
majority of the cases terminate fatally in from three to six months. 



ACETONURIA 737 

Prognosis. — All my cases died within less than a year after the 
diagnosis was made. True diabetes is a fatal disease in children. 

Treatment. — My 10 patients have been treated by Hmiting the 
amount of fluid taken, by restricting the diet, and by using the opium 
derivatives and arsenic to the point of physiologic effect, all without 
the slightest benefit. Bicarbonate of soda, furthermore, has been given 
in large dosage. The sugar output was reduced, but the patients 
showed not even temporary improvement in general condition. 

Diet. — The following are permissible articles of diet for a child ill 
with diabetes; Soup and broths made from meat, fresh and salt fish, 
shell-fish, occasionally egg, fowl, and game, smoked meats, sweetbread, 
cheese, spinach, celery, lettuce, cucumbers, cranberries, radishes, 
string-beans, asparagus, squash, cabbage, egg-plant, tomatoes, onions, 
turnips, mushrooms, gelatine jellies sweetened with saccharin, butter, 
cream, olive oil, cod-liver oil, lemon, grape-fruit, sour apples, black- 
berries, raspberries, watermelon. Nuts of all kinds may be eaten. 
Only bread and biscuits made from gluten flour should be used. It is 
impossible to procure a starch-free gluten flour; the flour, however, 
should not contain more than 20 per cent, of starch. 

ACETONURIA IN CHILDREN 

Acetone bodies occur in the urine in a wide variety of disorders, 
and are due to defective fat metabolism. They are present in 
diabetes, acidosis, inanition and malignant diseases. They may be 
present in practically every other disease of childhood, particularly 
in the exanthemata. 

The presence of acetone in the urine is not necessarily due to 
starvation or fever as we find it repeatedly when these conditions do 
not exist. We have found it repeatedly in children who were on a 
full carbohydrate diet. I have had two cases in which the patients 
showed a persistent acetonuria when on ordinary foods. The odor 
of the acetone breath had been noticed by the mother in each case. 
When the fats were entirely eliminated from the diet, the acetone 
disappeared. 

Illustrative Cases. — A boy six years of age had repeated seizures 
of periodic fever, the temperature ranging from 103 to 105°F. for four 
or five days, without other signs than excessive acetone in the urine. 
There had been several of these attacks during the previous two years, 
one about every two or three months. Treatment during the second 
year had not been attempted because the child recovered just as well 
without treatment. ''The fever had to run its course.'' With elimina- 
tion of fat, eggs and cane sugar from the diet, the attacks ceased, 
there having been no further attacks in five years. 

Children who readily develop acetonuria do not necessarily have 
attacks of true acidosis. Children, however, who are subject to attacks 
of true acidosis, will frequently have acetone in the urine with minor 
ailments with fever. 
47 



738 THE PRACTICE OF PEDIATRICS 

Treatment, — Fats must be given sparingly, cane sugar should 
be given in small quantities if at all. The usual diet contains sufficient 
carbohydrate to supply the needs of children, without cane sugar. 
If sugar is given it is best to use honey or maple sugar. 

PELLAGRA 

Pellagra is a systemic disease with a course typically marked 
by intermissions, affecting chiefly the skin, gastro-intestinal tract 
and nervous system. This disease has undoubtedly been endemic 
in Southern Europe for centuries and has long been known under 
such names as ''Alpine Scurvy,'^ ''Corn-bread Disease" and "Italian 
Leprosy." In the past two decades it has assumed special prominence 
in the Southern United States. The first recorded descriptions are 
those of Cazal and of Frapoli, made about the middle of the eight- 
eenth century. Today it is estimated that there are 100,000 cases 
in Italy and about 25,000 in the United States. 

Etiology. — Pellagra has been generally regarded as a metabolic 
disease of food origin rather than an infectious disease. Dermatitis 
of the characteristic type has been produced experimentally by Gold- 
berg, in individuals who were fed on a diet rich in maize and rice to 
the exclusion of animal and legume proteins, but whether the con- 
dition is due to deficiency of vitamins in maize, toxins derived from 
maize, poisons germinated in diseased corn or should be viewed as 
an example of anaphylaxis affecting particularly tissues sensitized 
by exposure to the sun has not been elucidated. Probably the 
most convincing view as to the origin of pellagra is that afforded by 
Alessandrini and Scala who state positively that it is a form of chronic 
acid intoxication caused by colloidal silica in drinking water and 
that the disease is localized and contracted only in those regions where 
the water supply is derived from clay soils. The explanation of the 
production of the disease is thus purely biochemical. The silica in 
colloidal solution attaches to proteid substances, and in this manner 
it fixes salts in the tissue cells of the body with the liberation of water 
and an acid — most frequently hydrochloric acid. The abstraction 
of the water and the diminution in alkalinity of the tissue fluids thus 
induced are productive of the drying of the tissues and the acid in- 
toxication which are so characteristic. 

Objections to the corn-meal theory and to the colloidal silica theory 
are met more or less convincingly by the respective advocates of each 
belief, so that it is perhaps best for the present to consider the matter 
undecided. 

Spring and fall are the seasons of greatest incidence of pellagra and 
similarly, these are the times for recurrences of the disease in aggra- 
vated form, once it has gained a foot-hold in a given subject. Most 
of the patients are between the ages of twenty and forty years and only 
about 9 per cent, are under the age of fifteen years. Cases observed 
in infants have never been proved in any degree hereditary. 



PELLAGRA 739 

Pathology. — The skin lesions exemphfy changes varying from an 
early erythema-like sunburn to thickening, pigmentation, and atrophy. 
Except for atrophic changes in the gastro-intestinal tract and fatty 
degeneration of the viscera, the most pronounced additional effects 
of the disease are confined to the spinal cord and brain. There is an 
endothelial proliferation in the capillaries of the pia with some connect- 
ive tissue increase, together with diminution in the nerve cells of the 
cortex and a considerable degree of gliosis. In the cervical cord the 
posterior columns show degeneration and in the dorsal region, the 
lateral columns are similarly affected. 

Symptomatology. — Following a prolonged "incubation" period 
marked by malaise, the average pellagrin gives evidence first of digestive 
disorder. This is indicated by redness and coating of the tongue 
frequently combined with actual stomatitis, flatulence and abdominal 
cramps, and diarrhea. At some period the last-named symptom oc- 
curs in fully 85 per cent, of cases. Almost as soon, if not equally early, 
the skin on the exposed parts of the body becomes the seat of an eryth- 
ema which develops into actual dermatitis. After a few weeks this in- 
flammation subsides, leaving the integument bronzed and indurated 
over a period of possibly many months. Mental derangement is com- 
mon but this symptom in children calls for only passing mention. Ver- 
tigo and headache are not infrequent and many patients show a 
positive Romberg test, and in ocular examination, changes in the retina 
and anomalies in the fundus reflex. The lower tendon reflexes are 
usually exaggerated but are at times diminished. The disease ordi- 
narily runs a sub-acute or chronic course with a tendency into sub- 
sidence during summer and winter with recurrences, as has been 
noted, during spring and fall. At these periods renewed severity in 
the skin and gastro-intestinal symptoms is the rule. Rises of tem- 
perature are not common. Malnutrition and anemia are invariably 
present, but the changes in the blood are in no way pathognomic. 
As a rule there is with the anemia, a slight leucocytosis and a moderate 
mononucleosis of from 10 to 20 per cent. The urine contains an 
excess of indican. 

Prognosis. — In children pellagra is ordinarily less severe than in 
adults. The adult mortality in the white race is estimated at 27 per 
cent. Complicating diseases including principally tuberculosis, ma- 
laria and hook-worm disease, doubtless contribute to this high 
mortality. Notwithstanding the tendency of the disease to run a 
chronic course over months and years, occasional acute cases are 
observed which prove fatal in as short a time as a fortnight. 

Diagnosis. — Pellagra may at times be confounded with eczema, 
scurvy, dysentery, tuberculosis and leprosy. The character and dis- 
tribution of the cutaneous lesions, the significant digestive disturbances, 
the peculiar course of the disease, and the history of other cases in the 
locality where the patient has resided are the points of greatest value 
in reaching conclusions in a given case. 

Treatment. — Preventive measures under Health Department 



740 THE PRACTICE OF PEDIATRICS 

supervision are essential in all communities where pellagra is endemic. 
Rules to govern the care and sale of corn in such communities are 
justifiable even though spoiled maize shall be proved to have no part 
in the causation of the disease. In view of the findings of Alessan- 
drini and Scala, drinking water should be provided which is free from 
excessive quantities of colloidal silica. All cases of the disease should 
be reported and given opportunity at least to have the advantage of 
institutional care. Goldberger recommends a diet rich in legumes and 
animal proteins, comprising milk, eggs and meat. Baths, salt rubs 
and massage are of special value in the management of cases in chil- 
dren. Most authorities administer arsenic, up to the physiological 
limit with intermissions of a few days at stated periods. Fowler's 
solution, atoxyl, and sodium cacodylate, are the preparations of choice. 
The last of these has been administered intramuscularly with good 
results by Deaderick and Thompson in dosage of three grains daily 
for an adult. Quinine hydrobromate has received particular ad- 
vocacy from Dyer. Serotherapy consisting in injections of serum 
from cured patients in healthy individuals, horse serum specially 
prepared according to the method of Nicolaier or serum from the 
patient himself (autoserotherapy) has given favorable results in a 
number of instances. 

Alessandrini and Scala believe the specific treatment is the ad- 
ministration of alkali to combat the acid intoxication produced by 
silica. The preparation of choice is sodium citrate, and this they ad* 
minister hypodermatically in a 10 per cent, solution. Oral admin- 
istration has also been found by them to be effective. Sodium 
bicarbonate may also be given freely. 

With any form of specific therapy symptomatic treatment must 
be employed and this demands the use of local applications for the 
skin lesions, intestinal astringents and antiseptics, and mouth washes, 
preferably containing chlorate of potash. Concurrent diseases 
such as hook-worm disease, and malaria should above all not be 
neglected. 

BERIBERI 

Beriberi is a disease the leading characteristics of which are mul- 
tiple neuritis and general oedema. The disease occurs in individuals 
whose food is deficient in certain vitamins. 

Etiology. — Beriberi is most common among rice-eating Oriental 
peoples but is endemic also in Brazil. The prevailing view held for a 
considerable time was that the specific cause was a microorganism 
which elaborates a toxin productive of neuritis. This view has now 
given place to the theory of food deficiency. Thus in the last two de- 
cades it has been established that the disease is prevalent only among 
peoples subsisting largely on a diet of rice which is "polished" or 
highly milled. The removal of the husk of the rice with the subjacent 
layer containing protein and fat leaves little but the starch and such 
rice has been shown to be deficient in anteneuritis vitamin and phos- 



BERIBERI 741 

phorus. The phosphorus pentoxid content is more or less directly 
proportionate to the amount of vitamin present and rice containing 
less than 0.4 per cent, of P2O5 will cause beriberi whereas rice contain- 
ing more than 0.4 per cent, will prevent beriberi.* Lack of vitamin in 
other starch food may similarly be responsible for the disease in people 
who do not eat rice, but subsist on a similar unbalanced ration. 
Overheating of food destroys the vitamin. 

Symptoms. — The leading manifestations are multiple neuritis 
and edema. When paralysis predominates, the term, dry or atrophic 
beriberi is applied to the disease, if the oedema is pronounced, the 
term wet beriberi is employed. Fever is seldom noted. Progressive 
asthma, weakness in the legs, cardiac palpitation and shortness of 
breath constitute the early manifestations. With the progress of the 
affection, symptoms of multiple neuritis become apparent, such as 
localized sensory and motor disturbances, coincidently localized edema 
develops in the extremities. Edema in the serous cavities of the body 
may follow. Nausea, vomiting and epigastric discomfort are common. 
Eventually foot drop, wrist drop and atrophy of the muscles affected 
by the neuritis develop. Blood examination reveals only the exist- 
ence of a simple anemia. The urine may contain albumin but seldom 
shows the presence of elements indicative of nephritis. Special forms 
of beriberi are the rudimentary type, the fulminating or pernicious 
form and infantile beriberi. The last type develops in infants of 
mothers who have the disease and is characterized by vomiting, oedema 
and symptoms of cardiac failure. 

Diagnosis. — Sporadic cases may be difficult of diagnosis. In 
children beriberi may be confused with nephritis, alcoholic neuritis 
and the neuritis of diphtheria. The habits of life of the patient, the 
distribution of the paralysis, and the urinary signs aid principally in 
confirming a doubtful diagnosis. Leprosy accompanied by neuritic 
manifestations is at times mistaken for beriberi. 

Prognosis. — The death rate varies markedly in different epidemics, 
ratiging from 2 per cent, among Japanese soldiers who were treated in 
military hospitals to as high as 50 or 60 per cent, among un- 
treated and ignorant peoples. In individual cases the prognosis 
should be guarded as in cases of post-diphtheritic paralysis because 
of the constant danger of sudden cardiac failure. 

Treatment. — Prophylaxis is most important. A well-balanced 
diet is sufficient to prevent the disease in an individual who will ob- 
serve the ordinary laws of hygiene. Nursing mothers who have the 
disease should promptly be made to cease nursing. Treatment of the 
developed disease is largely symptomatic. The diet should be light 
but nutritious, and contain the elements lacking in polished rice. 
Brewer's yeast, powdered rice husks and adzucki and mango beans 
are among the articles recommended as favorable to a cure. Rice 
itself should be removed from the diet. Saline laxatives are of great 
value and the use of these should be supplemented with the admin- 
* Barker — Monographic Medicine, vol. iv., p. 777. 



742 THE PRACTICE OF PEDIATRICS 

istration of diuretics such as potassium citrate or even diuretin. Car- 
diac stimulants which do not upset the stomach are of value at times 
but the routine use of digitalis has few advocates. For the vomiting, 
small doses of morphine are permissible if bromide proves ineffectual. 
As soon as oedema disappears affected extremities should be treated 
by passive movements, massage and electricity. Complete change of 
climate and environment does most to promote convalescence. 



XVIIL MISCELLANEOUS SUBJECTS 

HEREDITY AND ENVIRONMENT 

Many of the diseases, crimes, and failures of life are attributed to 
heredity, as are also vigor of body, attainments, and successes. Hered- 
ity and environment are two important determining factors in the 
life of the child. Both exert their influence over the individual. I had 
been taught, or in some way conceived the idea, that the influence of 
heredity was predominant; but as a result of the closest association 
with developing children, coming into intimate relations wdth hundreds 
of them and watching carefully their physical and mental development, 
the great influence exerted by environment, which often means only 
opportunity, has been forced upon me. It relegates heredity to the 
background. That certain diseases, such as syphilis and hemophilia 
may be transmitted from parent to child is undisputed; that certain 
physical states — the so-called constitutional vices — may also be trans- 
mitted is indisputable; but that much of natural physical weakness 
and hereditary tendencies may be overcome by the beneficial influence 
of envu'onment is now universally acknowledged. Heredity without 
favorable environment counts for little. Place a child or one of the 
lower animals, with an ideal heredity, under unfavorable conditions 
of environment and the favorable heritage counts for little. Feeding, 
care, and general good management shape physical future much more 
than does inheritance. In proof of supposed inherited mental traits, 
the offspring of criminals or drunkards are pointed out as showing 
how children follow in the footsteps of their fathers and mothers. It 
must be admitted that here the hereditary influence is bad, but one 
should remember that the environment has also been very unfavorable. 

Mental traits much more than physical conditions are apt to have 
an influence on the progeny, although here, again, brilliant fathers 
rarely transmit their higher mental powers to their offspring, as is 
proved again and again in the professional and business world. Many 
of the ills laid at the door of heredity are due to errors in early manage- 
ment. In the breeding of animals great stress is laid upon pedigree, 
and credit is given accordingly. It should be remembered, however, 
that the stock-raiser appreciates the value of the young of his herds, 
and they invariably get the care that is best calculated to develop the 
perfect animal, which is exactly what the majority of the children of 
the human family do not get. A well-bred animal, treated from birth 
to maturity as are many children, would cut a sorry figure in the animal 
world. 

Hereditary influences in animals are much more apt to obtain be- 
cause of the comparatively short period of growth from infancy to ma- 

743 



744 THE PRACTICE OF PEDIATRICS 

turity. The age of puberty in the lower animals is reached in most 
instances before the first year. In the human the development is much 
slower, supplying a much longer time for the influences of environment 
to make their impress upon the individual. 

CONSANGUINITY 

Much has been made of the supposed unfavorable influences exerted 
upon the offspring by parents closely related by blood. Consanguine- 
ous marriages, according to my observation, exert very little influence 
on the progeny if both the parents are in good health. 

Because the parents of animals or children are closely related, it 
does not follow that the offspring must or will show mental or physical 
deterioration. If there is a decided family taint or weakness, the tend- 
ency toward this weakness would be exaggerated in the offspring. I 
have known first cousins to marry and have perfectly normal children. 
In two instances under my observation fathers have impregnated their 
own daughters and normal children were the outcome. In the animal 
world the close breeding of brothers and sisters and parent and off- 
spring under my own observation was followed by normal vigorous 
young animals. Doubtless if this in-breeding were continued through 
successive generations the outcome would be disastrous. 

TEMPERATURE IN CHILDREN 

Normal Temperature. — The question is often asked: What is the 
normal temperature of a baby or young child of a given age? In order 
to answer this question from our own observation, a study of the matter 
was carried out at my suggestion by Dr. H. G. Myers, resident physi- 
cian at The New York Infant Asylum. This study comprised 59 cases, 
the ages varying from birth to one year. Only well children were 
selected for the observation, the majority being breast-fed. The tem- 
peratures in each instance were taken by the rectum for four minutes. 

It was found that the birth temperature in these infants ranged 
from 96° to 98°F., exceeding 98°F. in but five cases, when it was be- 
tween 98° and 99°F. In one it was 94°F. During the twenty-four 
hours following birth there was a rise in the temperature usually of 
about one degree. From this time on there was little variation in the 
temperature, when the child was well, regardless of the age. There 
would be a variation at different times of the day of a fraction of a de- 
gree, the temperature being higher in the evening. Upon looking over 
the charts upon which the results were chronicled, one is impressed by 
the uniformity of the temperature, which ranges, within fairly narrow 
Hmits, from 98° to 99.2°F. 

Instances when the temperature arose to 99.5°F. were occasionally 
seen, but 100°F. was very unusual. It is not claimed that the tempera- 
ture of a well child may not reach 100°F. ; in fact, there were occasions 
when it tose to 101°F. and illness could not be proved, and had not the 



TEMPERATURE IN CHILDREN 745 

temperature been taken for the purpose above mentioned, no elevation 
would have been suspected, for when next taken the temperature was 
normal. In these cases in which a rise was proved to be an early sign 
of illness, the recording of the temperature was discontinued and the 
first reading was not included in the observations. In one child a tem- 
perature of 103°F. was found. It remained at this point for three 
hours, when it feU to normal without any other manifestation of 
trouble. When, however, the thermometer registered over 99.5°r., 
some cause for the elevation could usually be discovered ; though it may 
have been nothing more than excitement or slight indigestion. 

Several years ago I personally made a similar series of observations 
at the Country Branch of the New York Infant Asylum upon 25 
healthy children under eighteen months of age. The temperatures 
were taken four times a day, the observations extending over an entire 
week. It was found that in these well children the temperature varied 
from 98° to 99°F.; and that when it rose daily above 99.5°F., some 
abnormal condition was always found to explain it. 

From these observations upon 74 well children, ranging in age from 
birth to eighteen months, whose temperatures w^ere taken several 
hundred times, it would seem that a daily rise above 99.5°F. may be 
considered abnormal. An occasional rise, however, considerably higher 
than this, as above mentioned, may occur and does occur in perfectly 
healthy children, without any special significance. 

Fever. — By fever, then, in infants and children we understand an 
increase above that which is considered the normal body-temperature. 

In children, for clinical purposes, the rectal temperature should 
always be taken. With those under five years of age the mouth ob- 
servation is unsafe, because the child is apt to bite off the thermometer 
bulb, and unreliable, because the lips will not remain closed the requi- 
site three or four minutes. The axillary temperature is thoroughly 
misleading and should never be depended upon. Thermometers 
should be carefully disinfected with alcohol after using. One-minute 
thermometers, according to my observations, are often unreliable and 
should not be used. 

Hyperpyrexia. — The highest temperature personally known to the 
writer was 111°F. This was as high as the thermometer could register. 
It occurred in a child of ten months who was in a convulsion which was 
one of the first symptoms of a tuberculous meningitis. The child had 
been placed by the parents in water at a temperature of llo°F., and 
had been in the water about ten minutes before the rectal temperature 
was taken. How much the temperature was due to the illness and how 
much to the hot water will never be known. The temperature re- 
sponded promptly to a cold bath. The child never regained conscious- 
ness and died of meningitis ten days after the initial convulsion. 

Fever as an Indication. — Fever may or may not be an index of the 
gravity of a disease. Thus we frequently see a temperature ranging 
from 103° to 105°F. in tonsillitis, acute indigestion, and stomatitis — 
ailments which respond very quickly to treatment and which present 



746 THE PRACTICE OF PEDIATRICS 

no serious aspects. In typhoid fever, pneumonia, scarlet fever, and 
diphtheria, however, when the temperature range is above 104°F., 
it is a symptom of considerable value, as indicating the severity of the 
infection. It is, therefore, not the fever itself, but the condition back 
of and associated with it, which makes it a sign of clinical value. In 
pneumonia children bear a comparatively high temperature, 104°F., 
for example, without much discomfort or danger; while in the acute 
intestinal disorders of summer an equal degree of fever is borne very 
badly, and if continued is of grave significance. This must be kept in 
mind in our dealings with fever. 

Importance of Hyperpyrexia. — When is a given temperature to be 
interfered with, is a question which concerns all practitioners. This 
depends to a great extent upon the cause of the fever and its effects 
upon the patient. If the fever produces diminished assimilation, loss 
of sleep, irritability, and restlessness, it will do the child harm by di- 
minishing the normal resistance to disease, and should be relieved 
whether it is 102°F. or 105°F. Interference is thus dependent not so 
much upon the height of the temperature as upon its effects upon the 
patient. 

The methods of relieving fever are: (1) Elimination: This applies 
particularly to the gastro-enteric tract and the skin. In a majority of 
the cases of high fever diie to acute indigestion, with resulting toxemia, 
a purgation, a bowel-washing, and a carefully adjusted diet for a day 
or two secure recovery. We remove the cause of a fever, and the fever 
subsides. Unfortunately, this means of controlling fever is limited to 
the gastro-enteric tract. (2) Diaphoresis, by which is understood the 
production of an excessive perspiration, will also relieve high tempera- 
ture. The most reliable way of bringing this about in a child is by the 
use of moderately heavy covering and the administration of the tincture 
of aconite, in doses of one-half to one drop every hour — eight doses in 
twenty-four hours; or liquor ammonii acetatis, two drams every two 
hours, for a child one year old. (3) Hydrotherapy: By far the most 
satisfactory means of controlling fever depends upon the local ab- 
straction of heat by means of sponging (p. 776), tub-baths (p. 779), and 
cool packs (p. 777). (4) Antipyretic drugs: Much which borders on 
the sensational has been written about the harmfulness of antipyretic 
drugs, particularly the coal-tar products. Used in large and frequent 
doses, they certainly may do a great deal of damage; under certain con- 
ditions, used in small doses and repeated at intervals of from three to 
six hours, they may be, and often are, of benefit. Aconite and liquor 
ammonii acetatis are of some value, as above stated, but they are of 
little value in controlling a very high persistent temperature. The 
coal-tar products furnish the best antipyretic drugs and may be used 
with safety, but should be used only when, for any reason, the local 
abstraction of heat by the application of cold is impossible. In many 
families there is too little intelligence to make a cold pack either possi- 
ble or safe. In severe cases of pneumonia and scarlet fever, and in the 
intestinal diseases, sponging often will not answer. Only a trained 



OBSCURE ELEVATION OF TEMPERATURE 747 

nurse or a very intelligent mother should be intrusted with a pack. 
Moreover, sponging and tub-bathing, if repeated too frequently, par- 
ticularly during the night, exhaust the child. Sponging or tub-baths 
are often strenuously objected to by parents as well as by the patient, 
and if the nurse is one of the family, her sympathy will counterbalance 
her judgment, and the result be far from satisfactory. Under such con- 
ditions, when the application of cold to the skin is impossible, a combi- 
nation of phenacetin and caffein, alone or with Dover's powder, has 
proved effective. The antipyretic treatment of scarlet fever is the 
same as that of pneumonia or typhoid fever. 

My use of antipyretic drugs has been confined almost entirely to the 
ignorant in private work and to dispensary patients. To a child 
of one year or under, one grain of phenacetin with 3^^ grain of citrate of 
caffein maybe given and repeated at three-hour intervals if the tempera- 
ture requires it; to a child two years of age IJ^^ grains of phenacetin 
and }y'2 grain of citrate of caffein at three-hour intervals; three years 
and over, 1 J^ to 2J^ grains of phenacetin with M to 1 grain of citrate of 
caffein, at intervals of from three to six hours. If there is much rest- 
lessness and irritabilit}', which is not thus controlled, Dover's powder 
may be added — J^ grain to each dose, for a child of from three to six 
months of age; J^ grain between six and twelve months; 1 grain after 
the age of two years is reached. It is always wise to caution parents as 
to the use of Dover's powder. They should be told that if the child 
becomes ''heavy" or unusuallj^ sleepy, the powders must be discon- 
tinued. That phenacetin and citrate of caffein cannot be given in solu- 
tion is unfortunate. Like all insoluble powders, the}" are best given 
in some mucilaginous mixture, such as barley-water or one of the 
cereal jellies. Fruit -juice or apple-sauce usually answers well. Anti- 
pyrin, for the reason that it forms a tasteless mixture with water, 
succeeds better with some intractable children, and maj' be used in the 
same doses as phenacetin, although as an antipjTetic the antipyrin is 
less efficient. 

OBSCURE ELEVATION OF TEMPERATURE 

Perhaps the most annoying cases in pediatric work are those with an 
elevation of the temperature for which no adequate cause can be dis- 
covered. In the section on Normal Temperature certain possible 
variations are given w^hich I regard as within the limits of health. 
When these boundaries are passed, when there is a temperature range 
between 99° and 101° or 102°F., or a temperature persistently at 100° 
or 101°r. without any apparent cause, and continuing for days and 
weeks, the medical adviser is not in an enviable situation. Such cases 
coming to the pediatrist through consultation or otherwise are some- 
times easy of solution. At other times, however, the cause of the fever 
may never be discovered, and the patient eventually gets well, leaving 
us still in ignorance of the cause. 

Active Exercise in Nervous Children. — This is not infrequently the 



748 THE PRACTICE OF PEDIATRICS 

cause of an elevation of the temperature. I have seen several cases of 
this nature. 

A few years ago I saw in consultation a country child three years 
of age whose temperature every afternoon at one o'clock was 102°F. 
The child, while not vigorous, showed no signs of illness. He ate well, 
slept well, and played hard. There was a slow gain in weight. The fever 
was discovered by the mother, who thought that the child, who was a 
blonde, looked flushed every day at about the same time. The tem- 
perature by rectum was normal in the morning and normal at night. 
This condition, to the attending physician's knowledge, had persisted 
for six weeks before I saw the patient. How long there had been a daily 
elevation of the temperature above the normal before the mother dis- 
covered it we have no means of knowing. The doctor, an excellent 
practitioner, had suspected, examined the child for, and treated him 
for, various diseases ; the first being malaria, with no response to quinin ; 
then typhoid fever, as by suggestion and constant inquiry the child 
came to imagine that he must be sick, and complained of languor. The 
fever continued, however, beyond the usual time allowance for typhoid 
fever and there were no other symptoms. There was no enlargement 
of the spleen and the blood had been repeatedly found negative to the 
Widal reaction. Other possible causes of the fever were also given at- 
tention. One day the doctor suggested tuberculosis. This aroused 
the family and friends and a consultation was the immediate result. In 
company with the doctor, I saw the child at his home. I found a 
rather thin boy, three years old. The family history was excellent. 
There was one other child, six years of age, who was well and a good 
specimen of robust boyhood. The patient had never had a pulmonary 
disorder and no disease of the respiratory tract other than slight bron- 
chitis. There was no apparent association of the condition with any 
intestinal or infectious disease. An exhaustive physical examination 
failed to reveal any abnormality other than a small umbilical hernia 
and a slight enlargement of the inguinal and submaxillary glands. The 
blood was not examined. The child was pale, and doubtless a blood 
examination would have revealed a mild secondary anemia. The 
appetite was fairly good; the bowels were reported regular and his 
stools normal. The child had not been kept in bed, as the family did 
not consider him very ill. The physical examination being negative, I 
questioned the mother very closely as to the child's habits of life. I 
found that he rose at 7 a. m., had breakfast at 7.30, and played with his 
big brother and two older boys until 1 o'clock, when he had dinner. A 
glass of milk and a piece of bread and butter were given as a luncheon 
at 11 A. M. I found that he played very actively, kept up with the 
older boys, and was unhappy when he was not with them. Attempts 
had been made without success to entertain him with less strenuous 
play. It was at midday, sometimes before, sometimes after dinner, 
that the temperature reached the highest point. It seemed to me that 
here, probably, was a case of fatigue temperature. I accordingly sug- 
gested that the boy be undressed and put to bed at 11.15 A. M. after 



OBSCURE ELEVATION OF TEMPERATURE 749 

the light luncheon and be made to rest and sleep if possible. At 1.15 
he was to be taken up for dinner, his temperature first being taken. 
These instructions were faithfully carried out, and this ended the daily 
rise in temperature. The case was one of an active, nervous child 
becoming over-tired in his attempts to hold his own with older and 
stronger boys. The patient improved rapidly in his physical condition 
and is now, after an interval of several years, perfectly well. 

Another child, four years of age, was seen in consultation with a 
New York physician, because of a daily elevation of the temperature 
ranging from 100° to 102.5°F., which had continued for six weeks. 
The child was thriving and otherwise perfectly well No cause for the 
fever could be discovered in his physical condition. He had a noisy, 
excitable nurse, who was inclined to exciting games and rough play with 
the boy. With dismissal of the nurse the fever ceased. 

Otitis. — Persistent fever, following the acute catarrhal affections 
of the upper respiratory tract and the exanthemata, is sometimes ex- 
plained by a suppurative process in the middle ear, without other 
symptoms than the fever. 

Encysted Empyema. — A small area of encysted empyema may ex- 
plain a persistent fever following pneumonia. Holt describes a most 
interesting case of this nature in which there was for over four weeks a 
temperature range from 100° to 105°F. Autopsy showed a small 
collection of pus between the diaphragm and the lung. 

Periodic Fever. — Not infrequently we see cases which show some 
of the clinical signs of malaria as regards periodicity in the temperature, 
but without splenic enlargement or the presence of the malarial organ- 
ism in the blood. Yet, often, these cases quickly respond to full doses 
of the bisulphate of quinin. 

Typhoid Fever. — Occasionally, a low persistent temperature eleva- 
tion, obscure for a week or two, proves to be due to a mild typhoid. 

Tuberculosis. — An elevation of the temperature is sometimes the 
first premonitory symptom of tuberculosis. Tuberculosis in a child, 
however, is usually an active process when it involves the lungs, and 
can readily be made out. When other parts are involved, such as the 
bones, glands, skin, or peritoneum, the manifestations are usually 
sufficiently plain to indicate the condition. 

Intestinal Infection. — Intestinal infection due to chronic consti- 
pation may be the cause of persistent fever. In a suspected case, 
in the absence of bowel symptoms, it is well to give a laxative and 
put the child temporarily on a reduced diet consisting largely of 
carbohydrates. 

Pyelitis. — Pyelitis of mild degree may produce a slight elevation of 
the temperature which may be difficult of solution. Several speci- 
mens of the urine may fail to reveal pus. In doubtful cases the urine 
should be drawn by a catheter and examined by culture methods. 

Unexplained Elevations of Temperature. — I have known children 
to exhibit an unexplained temperature of from 100° to 101. 5°F. for 
weeks without any other signs of illness. I have employed all the newer 



750 THE PRACTICE OF PEDIATRICS 

diagnostic laboratory methods, and I have seen such patients recover 
without a diagnosis. Of one thing, however, we may rest assured : If 
a competent, thorough examination does not reveal the cause of the 
temperature, we are safe in concluding that there is nothing of a very 
serious nature back of it. 

Periodic attacks of elevation of the temperature from 101 to 104, 
explainable only on the grounds of a disturbed metabolism are occa- 
sionally encountered. Other than acetone in the urine these cases are 
negative throughout. The pyrexia lasts four or five days and then 
subsides by crisis. The acetone is not the result of starvation, and the 
case is not one of true acidosis. 

Illustrative Case. — The history of a case of this kind, which gave me no end of 
trouble and annoyance, may not be without interest. 

The patient, an eight-year-old boy, was the only son of a habitually anxious 
mother, who had unfortunately learned to use the clinical thermometer. She took 
her boy's temperature after school one day early in December. She found that the 
thermometer registered 100. 5°F. I was consulted, saw the boy in the evening, 
took his temperature by mouth, with my own thermometer, and found it 100. 8°F., 
with no other evidence of disease. He was perfectly normal in every other respect. 
He maintained that he felt well, did not need a doctor, and wished to be let alone 
to study his lessons. The following morning the temperature was 100°F. ; in the 
evening it was nearly 101°F. For six weeks this temperature range continued, 
never below 100°F., never higher than 101. 2°F. The boy, against my advice, was 
taken from school. He was put to bed, and a half-dozen consultants saw him with- 
out shedding any light on the case. Finally the mother became reconciled to 
"doing nothing" for her son, and he was taken to a nearby winter resort. I sug- 
gested to the father that before leaving town he should "accidentally" drop the 
thermometer on the hardwood floor and then refuse to have another in the house. 
This he managed to do, straightway. The boy had an excellent time at the winter 
resort, played with his sled in the snow, skated on the lake, fell through the ice 
once and received a thorough wetting, without harm. In three weeks he returned, 
improved as much as any city child improves from a country outing. His tem- 
perature was not taken during these three weeks at the winter resort and has not 
been taken since, except when there have been evidences of illness. He is now 
developing along normal lines and is a fair physical specimen for his age. 

ANESTHETICS 

That the use of anesthetics in children is attended with consider- 
able danger is proved by statistics relating to the subject. That the 
greatest care and judgment should be exercised in the selection of an 
anesthetic for a child is readily understood. 

Ether and Chloroform. — As a routine anesthetic for the young, ether 
is preferable because of its safety. The popular belief that chloroform 
is without danger is an error and not sustained by statistics. There 
are conditions, however, when ether is contraindicated. In cases in 
which there is bronchial involvement, ether increases the bronchial 
secretions and produces a free flow of saliva, which is liable to be as- 
pirated into the lungs. In case of any obstruction to respiration, as 
in laryngeal diphtheria, retropharyngeal abscess, and enlarged glands 
which may encroach upon the air-passages, chloroform, and not ether, 
should be employed. Ether is further contraindicated in scarlet 
fever or in nephritis. In such cases chloroform is to be selected. 
Chloroform is to be used also for the sake of convenience, if other 
conditions allow, in operations about the mouth and the nose. Chlo- 



CARCINOMA 751 

roform is contraindicated in general weakness, exhaustion, collapse, 
and in anemia. Ether given by the drop method should be used in 
these cases. Statistics of chloroform anesthesia show a considerable 
mortality in operations for adenoids and enlarged tonsils. The inter- 
ference with respiration and the sudden hemorrhage make chloroform 
dangerous in these operations. In heart disease with imperfect com- 
pensation any anesthetic is dangerous, but ether by the drop method 
is the least dangerous. 

Nitrous Oxid Gas. — Nitrous oxid gas, which of late has become very 
popular, should be used with caution in children under two years of age. 
Young children are very easily asphyxiated by gas; the younger the 
child, the greater the danger. Under two years of age, sudden and 
alarming asphyxia has resulted from its use. It should be used, there- 
fore, very sparingly and the patient watched most carefully for signs of 
cyanosis. The use of gas in children usually precedes the administra- 
tion of ether, as it renders the use of the latter much easier for the 
patient. It is contraindicated, however, in any condition where 
dyspnea is present; in fact, in any illness in which respiration is im- 
peded, gas is dangerous. The combination of gas and ether in such 
cases is not as safe as chloroform, which is to be given in a minimum 
amount with oxygen as a safeguard. 

Danger-signals with Ether: 

Marked cyanosis; stertorous breathing; rapid pulse; dilated 
pupils; short, quick, gasping respiration. 
Danger-signals with Chloroform: 

Pallor; ashen color; feeble, shallow respirations, gasping in 
character; dilated pupils and separation of the eyelids; 
slow, feeble heart action. 
Danger-signals During Gas Administration: 

Cyanosis; jerking respirations; dilated pupils; convulsive move- 
ments of any portion of the body. 

Ethyl Chlorid. — The use of ethyl chlorid is in the experimental 
stage. Statistics show quite a mortality from its use. It should 
never be administered after unconsciousness has set in. In case the 
condition of the patient shows any of the danger-signals, it should 
temporarily or permanently be discontinued and some other form of 
anesthetic substituted. 

CARCINOMA 

Carcinoma in children is of very unusual occurrence. I have never 
seen a case either in hospital or private work. 

Phillipp has collected 390 cases of carcinoma reported in children 
under fifteen years ; among these he found but 87 which were undoubt- 
edly true cancers. To these he adds 6 cases, making 93 cases of cancer 
in childhood. This report was published in 1907. In 1911 Ribbert 
stated that no other cases had come under his notice, so that about 
93 cases of cancer (real) have been reported in children. Three- 



752 THE PRACTICE OF PEDIATRICS 

fourths of these occurred in older children, between eight and fifteen 
years of age; only one-fourth prior to eight years. 

The incidence of sarcoma for comparison is not given. 

OBESITY 

Exceedingly fat children will usually be found to be hearty eaters 
and of inactive habits. Obesity is rarely a serious condition, and or- 
dinarily requires little more than certain restrictions in diet and regu- 
larity in exercise. Generally, this is not difficult to obtain, as the 
patients are usually very anxious to reduce the weight because of the 
attention they attract and the remarks the condition occasions in 
public places and among school-fellows. 

Treatment. — Diet. — In such cases I direct that all fatty foods, in- 
cluding butter and whole milk, be excluded from the diet. Skimmed 
milk may be given in moderation — not over one pint daily. A portion 
of this may be used on the cereal, and the remainder as a drink. The 
use of sugar, including candy and sweets of all kinds, is to be forbidden. 
Saccharin dissolved in the milk may be used on the cereal and in mak- 
ing stewed fruits and plain puddings palatable. Green vegetables 
may be given freely. The evening meal should be very light, consist- 
ing usually of broth, a small amount of stale bread, and stewed fruit. 

Exercise. — During the warmer months golf, swimming, tennis, 
horseback exercise, and the bicycle are advised, a definite time, in hours, 
being prescribed each day for some active physical exercise. During 
the cold months roller-skating, ice-skating, horseback-riding, out-of- 
doors when possible and indoors on inclement days, when the means 
are at hand, together with long walks, should occupy part of the daily 
life. A schedule should be prescribed and written out for each day, 
depending somewhat upon the station in life of the patient, not only as 
regards food, but also as regards outdoor exercise. In this way, under 
an established system of living covering the entire day, there will 
result, if the family cooperate, a reduction of the obesity with marked 
improvement in the patient 's general condition. 

Drugs. — The use of thyroid extract and other drugs for the reduc- 
tion of weight in children is not to be advised. 

During the treatment the child should be weighed regularly, as too 
pronounced results are not desired. 

HEMATOMA OF THE STERNOCLEIDOMASTOID 

This condition is the result of trauma which takes place during de- 
livery. The muscle is torn as the result of pulling by forceps or ma- 
nipulation on the part of the accoucheur in the endeavor to bring 
down the after-coming head in breech cases. 

The injury consists in a rupture of the muscle-fibers and blood- 
vessels. A tumor forms within the muscle-sheath, which may be small 
or large, involving the muscle structure in its entire width. There is 



HERNIA AT THE UMBILICUS 753 

always an associated contraction of the muscle, which places the head 
in the wry-neck position, drawn toward the affected side. The tumor 
is usually located in the lower third of the muscle. I have seen it im- 
mediately at the attachment to the clavicle. 

The tendency of these cases is toward complete recovery. The 
tumor is absorbed, but a shorter muscle is sometimes left, which holds 
the head in the characteristic position. 

Treatment. — It has seemed to me, in the observation of a large 
number of cases, that massage hastened the absorption of the tumor. 
The massage should be practised for fifteen minutes three times a day. 
At the same time a moderate stretching of the muscles should be 
attempted by rotating the head toward the unaffected side and up- 
ward. All cases eventually make complete recoveries. 

HERNIA AT THE UMBILICUS 

Protrusion of the abdominal wall at the umbilicus may be due to 
an improper development of the blastodermic layers, with non-union 
(exomphalos, hernia into the umbilical cord) ; or may result from a true 
fetal hernia after the umbilicus is lined with peritoneum, or a hernia 
occurring after birth through a weak umbilical scar. 

Hernia of the Umbilical Cord 

Morbid Anatomy. — This condition is a true fetal defect, due to a 
failure of union of the blastodermic layers, leaving as the anterior wall 
of the abdominal cavity a membrane covered with amnion externally 
and with peritoneum internally. Through this weakened parietal wall 
may occur a protrusion usually the size of a pear or an apple, but which 
may range from the size of a small finger-tip to that of a child's head. 
The tumor is glistening and transparent, and shows through its walls 
the contents of the sac. These may include any or all of the abdom- 
inal contents, stomach, Hver, Meckel's diverticulum, omentum, 
intestines. Occasionally the child will be born eviscerated from the 
bursting of such a hernia in labor; and often its occurrence is asso- 
ciated with that of a spina bifida. 

The covering of this variety of hernia falls off with the drying up 
and dropping off of the umbilical cord. The contents are thus exposed. 
If the defect is small enough, it may granulate and epitheliahze ; but if 
this does not happen and operation is not resorted to, peritonitis and 
death will probably ensue. 

Treatment. — Operation offers a means of cure in these cases. Kindt 
reports 50 cures in a series of 65 operations. 

The management, therefore, should not be expectant. In view of 
the good results of operation, an attempt should be made as soon as 
possible after birth to close the opening in the abdominal wall either 
by cutting away the sac in its entirety and suturing the abdominal 
walls together, or by separating the amnion from the peritoneum, re- 

48 



754 THE PRACTICE OF PEDIATRICS 

placing this and its contents into the abdominal cavity, and then sut- 
uring the walls. 

Congenital Umbilical Hernia 

Etiology. — This type of hernia occurs after the closure of the vis- 
ceral layers, and is due to pressure within the abdominal cavity and 
to the comparative weakness of the upper part of the umbilical ring, 
and to the extension of peritoneum surrounding the umbilical vessels, 
which, forming a sac, directs the force of the increased intra-abdom- 
inal pressure. It may occur through the linea alba, just above the um- 
bilical ring, either alone or in conjunction with hernia at the umbilicus. 

Prognosis. — The tumor is usually from J^ to 1 inch in diameter, 
and may protrude as much as IJ-^ inches. There is seldom any discom- 
fort, although when the contents are extruded and reduced, there may 
be some pain. Danger of strangulation is slight, and the prognosis 
as regards cure is good. The time required ranges from six months to 
two years. The younger the child, the quicker the cure. 




Fig. 111. — Umbilical hernia reduced and adhesive plaster applied. 

Treatment. — Treatment consists in retaining the hernia and allow- 
ing the opening to close, and is, therefore, entirely mechanical. Opera- 
tion is rarely necessary. Of 2000 operations for hernia in children 
under fourteen years of age at the Hospital for Ruptured and Crippled, 
but 1.3 per cent, were for umbilical hernia. By far the most effect- 
ive method of treatment is to bring together over the umbihcus (Fig. 
Ill) two folds of skin, so that they meet in the median line and invert 
the umbilicus. These folds of skin thus form a splint which is retained 
by a strip of moleskin adhesive plaster 1 or 2 inches wide and suffi- 
ciently long to hold fast to the skin — usually about 4 to 6 inches. This 
method in my hands has proved the most satisfactory and has been 
followed by the most rapid cures. 

The objection to the use of a covered button or any form of pad, 
many of which have been recommended, is that unless it is very large 
the pad is apt to make strong pressure upon the abdominal opening, 
and while keeping the hernia reduced, prevent rapid closure of the ring 



INGUINAL HERNIA 755 

itself. A pad or button may also interfere with the circulation and thus 
hinder the nutrition of the muscles and cause the weakness to persist. 
Umbilical trusses and bandages have been used repeatedly, and all 
have proved hopeless failures, and for one reason chiefly — the dif- 
ficulty of keeping them in position. Any intelligent mother or 
nurse can be taught to apply the plaster as suggested above. The 
child may be bathed with the plaster in position. Ordinarily, it is 
best to apply a fresh piece every fifth day. Irritation of the subjacent 
skin sometimes occurs, and if this tendency exists, folds can be made 
at right angles to those previously made and the plaster applied 
again at right angles to the folds. By this means the excoriated skin 
remains uncovered. 

INGUINAL HERNIA 

Inguinal hernia is of rare occurrence in female infants, but is com- 
paratively frequent in males. It may be present at birth, or develop 
at a later period. The right side is more frequently involved. Double 
hernia, however, is not at all infrequent. 

Etiology. — Anatomic Conditions. — The special anatomic condition 
predisposing to inguinal hernia in infancy is the short and direct course 
of the inguinal canal. In the infant the internal abdominal ring is 
almost directly behind the external ring, and on practically the same 
level. Incomplete closure of the inner opening, combined with weak- 
ness of the peritoneum in the neighborhood of the ring, thus affords 
easy egress to the hernia. At the femoral canal, on the contrary, the 
possible hernial opening is quite adequately protected, owing to the 
close relationship existing in the child between the anterior superior 
iliac spine, Poupart's ligament, and the spine of the pubes. Conse- 
quently femoral hernia in childhood is rare. 

A more direct and exciting cause of hernia is the pressure exerted 
by the abdominal muscles in crying, particularly from colic, and during 
paroxysms of whooping-cough. 

Diagnosis and Differential Diagnosis. — Inguinal hernia in infants 
is usually readily reducible, and this facts permits of making the diag- 
nosis positive. 

Strangulated inguinal hernia may be confused with hydrocele of 
the cord, enlarged inguinal glands, and undescended testicle. 

In hydrocele the tumor is translucent, which may be readily proved 
by means of the following light test : A piece of dark, stiff paper is rolled 
in tube form, so that the orifice is J^ inch in diameter. One end of the 
paper tube is placed over the tumor, which is supported while a lighted 
candle is placed underneath. The observer 's eye is now applied to the 
other end of the tube. If the light is not transmitted through the mass, 
hernia in all probability is present. 

Further, if strangulated hernia has persisted for even a few hours, 
there will be vomiting and pronounced abdominal distention. 

In the condition known as undescended testicle the testicle is absent 
from the scrotum and may be demonstrated in the canal as a small, 



756 THE PRACTICE OF PEDIATRICS 

ovoid, movable mass. I have known of the wearing of a truss over an 
undescended testicle. 

When due to enlarged inguinal glands, the tumor is placed to the 
left or right of the canal. It is firm, hard, and fixed, and usually more 
than one gland is involved. It would seem that there should be no 
necessity for confusion in the differentiation of a gland mass. 

Prognosis. — The prognosis for cure of uncomplicated hernia without 
operative procedure is good. At least 98 per cent, of my cases are 
cured in from six months to one year, through the use of suitable 
appliances. 

Treatment. — The treatment of inguinal hernia in infants and 
young children is by mechanical appliances or by operation. In 
infants under one year of age operation is rarely required. The most 
satisfactory means in my hands for treating inguinal hernia has been 
the Hood frame truss, made of hard rubber. Measurement for the 
truss is taken around the hips on a plane with the hernia. The truss, 
if placed in hot water for a few seconds, or warmed slightly before a 
fire, can readily be bent, so as to fit the patient comfortably. When 
the truss is removed for the purpose of cleansing, which should be 
done twice a day, a helper should be at hand to maintain support at 
the ring, so that there shall be no descent of the hernia. One descent 
may mean that several weeks' care has been brought to naught. The 
child should wear the truss day and night. The skin, where subject 
to pressure, should be kept well powdered when the truss is first ap- 
plied, and the child is often made more comfortable by placing ab- 
sorbent cotton beneath the hard-rubber pad. 

As the child grows the truss will have to be changed frequently. 
Its use should be continued for at least six months after the last descent 
of the hernia. Operation is required when the hernia becomes strangu- 
lated, and this procedure is always to be advised for older children if a 
cure is not affected after two years' treatment by a truss. Many of my 
cases have entirely recovered in less than six months. The use of the 
truss, in such instances, however, is continued with a view to protecting 
the parts and preventing a recurrence of the hernia under stress. 

VENTRAL HERNIA 

This form of hernia is of congenital origin, and is only occasionally 
seen in infants. It may be associated with umbilical hernia or it may 
occur independently. It may be due to a failure of the recti to unite 
in the median line, or it may be due to weakness or imperfect develop- 
ment of the fibers of either muscle. Muscular atrophy following 
poliomyelitis was the cause in two of my cases. 

There is rarely any great protrusion of the abdominal contents, 
as in the other forms of hernia. Usually a ventral hernia manifests 
itself in a fullness or distinctly localized elevation of the skin over the 
site of the absent or weakened muscle tissue in the abdominal walls. 
The usual location is in the hypochondrium. I have seen from two 



DIAGNOSIS IN BONE AND JOINT DISEASES 757 

to three hernias in one subject in this locality. In one case the hernia 
was in the right lumbar region. Not all cases require treatment. 

Treatment. — The apphcation of a four-inch strip of zinc oxid ad- 
hesive plaster 2 or 3 inches wide, placed flat on the skin over the hernia, 
is all that will usually be required. The support thus furnished must 
be continued for several months. Operation may sometimes be neces- 
sary, but has not been required in my cases. 

Diaphragmatic Hernia. — These cases are very unusual. Only one 
has come under my observation. In this case, as in others reported, the 
defect was located at the left anterior border of the diaphragm. This 
allowed the intestines to pass into the pulmonary cavity, displacing 
the heart and the lungs. As may be imagined, the physical chest signs 
thus produced are most unusual and puzzling. 

DIAGNOSIS IN BONE AND JOINT DISEASES * 

It is not within the province of this book to enter the domain of 
orthopedic surgery. The practitioner, however, is the first to see cases 
of illness regardless of their nature, and bone and joint diseases are no 
exception to the rule. For this reason these diseases will be considered 
largely from the standpoint of diagnosis. In the examination for bone 
and joint diseases in runabout and older children the patient should 
invariably be stripped. He should then be encouraged to move about, 
to run and play, to sit down, to lie down, to roll over on his stomach and 
back again. He may be asked to pick up toys, to walk up and down 
stairs, to climb into a chair. By these means limitation of motion, a 
most valuable symptom in joint disease, is made apparent. 

Acute Peri-arthritis. — In infants and young children observed in 
hospital work an infection of the peri-articular structures is not at all 
uncommon. The symptoms presented are those of superficial swelling, 
and at times redness and pain upon manipulation. Fluctuation will be 
present if the case is at all advanced. In my cases the shoulder- and 
elbow-joints have been the more frequently involved. The disease 
may be due to any of the pathogenic organisms. In a recent case an 
examination of the pus showed pure influenza bacillus infection. The 
gonococcus may produce either a peri-arthritis or an arthritis. Eleva- 
tion of temperature is an inconstant symptom. It may be present or 
absent. 

Arthritis. — In arthritis the symptoms are usually more urgent. 
The temperature is higher, 102° to 104°F., and there is complete loss of 
power in the limb involved, associated with pain, swelling, and redness. 
As in peri-arthritis, any one of the pyogenic organisms may be the in- 
fecting agent. 

Gonorrheal Arthritis. — In gonorrheal arthritis the lesion is apt to 
be multiple. I have seen as many as five joints involved in one patient. 
The small joints of the hands are particularly apt to be involved in in- 
fants with gonorrheal arthritis. Arthritis and peri-arthritis are often 
confused with rheumatism. In the non-gonorrheal cases the urgency 



758 THE PRACTICE OF PEDIATRICS 

of the constitutional symptoms and the severe local lesion, with the 
rapid development of pus, renders a diagnosis fairly simple. In gon- 
orrheal arthritis one may have to look to the age as a point in differenti- 
ation. Children under eighteen months rarely have rheumatism, and 
in the very young, successive, severe, inflammatory joint infections 
should always arouse the suspicion of an infectious arthritis. 

Joint Tuberculosis. — While tuberculosis may develop in any bony 
structure, that form with which we are particularly concerned in 
diagnosis affects the hip and spine. 

Tuberculosis of the Spine. — Tuberculosis of the spine may occur 
in quite young infants. My youngest patient was nine months of age. 
While the symptoms vary somewhat, depending upon the location of 
the inflammation, one symptom is almost always present early in the 
illness — -stiffness, a tendency to hold the body rigid. The child moves 
awkwardly. If the cervical vertebrae are involved, the head will be 
held fixed on the shoulders, often with a bearing slightly either to the 
right or the left, resembling the attitude of torticolHs. If the dorsal or 
lumbar vertebrae are involved, the child holds the body erect and all 
movements are made with care and caution. The shoulders are 
thrown backward, the child assuming a military attitude. Bending 
the body is difficult. When the child attempts to pick an object from 
the floor, the spine is held rigid, while extreme flexion takes place in the 
knees in order to bring the hand to the floor. Pain reflected anteriorly 
may be present, not always early in the case. 

In every motion the child attempts to protect the sensitive spine, 
making all voluntary motions with precision and apparent forethought. 

Early in the disease there is no deformity. The first objective sign 
to appear is a projection or undue prominence of one or more of the 
spinal processes. After the development of the angular bony deformity 
the disease is unmistakable. 

Tuberculous Disease of the Hip. — This is very rare in infancy. 
The first symptom is a slight limp, due to spasticity of the hip muscles, 
which causes the child to step short. The onset of the disease is very 
gradual, and the limping may disappear for weeks at a time and return 
again, and again disappear. Pain in the anterior portion of the thigh 
just above the knee is an early symptom. 

Illustrative Case. — A boy twelve years old who came under my care had a 
periodic limp or short step for six years; he had been treated for various conditions, 
particularly for rheumatism. I referred him to an orthopedist, who, after several 
weeks of observation assisted by an a:-ray, pronounced the condition tuberculous. 

A shortening of the gluteal fold and a general flattening of the hip 
with an increased prominence of the trochanter are characteristic of 
hip disease. 

The tendency to spasticity of the hip muscles furnishes a most 
valuable diagnostic aid. There is a general limitation of motion as 
compared with that of the sound side: abduction, adduction, flexion, 
extension, and rotation are all retarded. The joint appears fixed. 



DIAGNOSIS IN BONE AND JOINT DISEASES 759 

Tilting of the pelvis, due to the muscular spasticity, consists in an ele- 
vation of the patient's back from the table when the extended leg of 
the affected side rests fully upon the table. In more advanced cases 
there is the e version of the foot. 

Outward rotation of the entire Hmb and apparent lengthening, pain, 
inability to walk, and abscess are the outcome in cases unsuccessfully 
treated. 



XIX. SUGGESTIONS IN MANAGEMENT 
VACCINATION 

Every infant in fair health should be vaccinated. The vaccination 
should be done as soon as the child is thriving on a rational diet. The 
younger the child at the time of vaccination, the less the constitutional 
disturbance. In well infants, vaccination should never be delayed 
beyond the fifth month. 

The Site. — The site selected for the vaccination in boys is usually 
on the left arm, at about the point of insertion of the deltoid, and in 
girls on the outer aspect of the calf of the leg. I have found, however, 
that it is a matter of much more convenience to the mother in dressing 
and handling the child if the leg is selected in both sexes. The dressing 
is more easily applied to the wound and can more readily be kept in 
place on the leg. Further, in the manipulation necessary in dressing 
and undressing, much less discomfort is occasioned when the sore is on 
the leg. 

The Method. — Before scarification of the skin, the site selected should 
be well scrubbed with common soap and water, dried, and then washed 
with alcohol. The area of scarification should not be over one-quarter 
of an inch in diameter, and should be sufficient to produce only a light 
flow of serum. A deep scarification, producing a free flow of blood, 
is very apt to be unsuccessful. The best scarifier is an ordinary sew- 
ing-needle, which should be sterilized by placing the point for a few 
seconds in an alcohol flame. The virus which is furnished in hermeti- 
cally sealed capillary glass tubes is the safest to use. The drop of virus 
is to be deposited on the abraded surface and rubbed well into the 
wound, using the side of the needle for this purpose. When the 
wound is thoroughly dried, a protective dressing should be applied. 
The safest and most convenient is a sterile gauze bandage, which is 
wrapped several times around the arm or leg and secured with a safety- 
pin. On account of the shape and position of the parts, the bandage is 
very apt to become displaced downward. In order to prevent this, a 
strip of adhesive plaster one inch wide and five or six inches long may be 
placed over the bandage at right angles to it; the middle portion of the 
plaster readily adheres to the bandage, and the two ends, at least two 
inches long, are anchored to the skin. 

The After-treatment. — The mother should be instructed to report 
five days after the vaccination. On the fifth day the dressing may 
be removed, and if the vaccination is successful, the characteristic 
pearl-like vesicle will be present. If, on account of accident or rubbing 
of the parts by the patient, the vesicle is broken, the non-adhering 
gauze should be carefully cut away around the sore, allowing that which 

760 



VACCINATION 761 

adheres to remain. Under no conditions should the wound be opened. 
Again, a gauze dressing should be applied and kept in position by ad- 
hesive strips. At the end of the exudative stage, usually about five or 
six days, the dressing should again be changed, either by the mother or 
the physician, and renewed until the crust falls, the third to the fourth 
week after the vaccination. 

If there is no sign of the vesicle in ten or twelve days, the vaccina- 
tion, if primary, should be repeated. Revaccination should be prac- 
tised at least once in five years, and at more frequent intervals during 
epidemics of smallpox. 

Complications. — If vaccination is properly performed, the dangers 
attending it are practically nil. That death and serious results have 
followed vaccination is no argument against its use, but a grave reflec- 
tion on the manner in which, as a rule, it is performed. The scarifica- 
tion of bacteria-laden skin, producing at the outset an open wound 
which is indifferently or not at all protected from further infection, is 
very apt to produce complications of a troublesome and often serious 
nature. Erysipelas, extensive cellulitis, and sloughing of the parts 
as the result of careless vaccination are not infrequently seen at out- 
patient departments for children. In two cases I have seen reinocula- 
tion, as the result of scratching the sore, the virus being transferred in 
one case to the upper lip and in the other to the upper eyelid. 

Vaccination Shield. — There is not a vaccination shield on the mar- 
ket, with which I am familiar, that is safe for use. Some cause a 
maceration of the wound, others allow a free entrance of bacteria, while 
still others prevent a free superficial circulation of the blood and in- 
crease the chance of ulceration. Moreover, the shields are very apt 
to become displaced, causing a rupture of the vesicle, with resulting 
infection. 

Constitutional Disturbance. — A certain degree of constitutional 
disturbance is present in every case in which the vaccination is suc- 
cessful. After the first month, however, the younger the child, the less 
the constitutional disturbance. Children vaccinated during the second 
or third month suffer practically no inconvenience. There is a rise in 
temperature — from 100° to 101°F. — for a day or two, and when the 
process is at its height, perhaps a slight degree of restlessness. Time 
and again I have seen children, vaccinated at this age, pass through the 
various stages without manifesting the slightest discomfort. In older 
children the severity of the constitutional symptoms appears to in- 
crease with the age. Thus, a child in the second or third year may 
have fever, 102° to 104°F., loss of appetite, coated tongue, and moder- 
ate prostration. Very active symptoms rarely last longer than three 
days unless there is considerable accompanying cellulitis. 

Local Applications. — Active treatment, except for relief of the imme- 
diate constitutional symptoms, is rarely required. Even when there is 
an active cellulitis I have found it advisable not to attempt local 
applications, such as lotions or compresses. All ointments have a 
tendency to dissolve and loosen the crust, producing an open wound. 



762 THE PRACTICE OF PEDIATRICS 

When, on account of suppuration, the crust falls, leaving a deep ulcer 
formed by granulation tissue, active local treatment will be required. 
Such ulcers are often seen in outpatient work. A wet dressing of a 
saturated solution of boric acid has answered well in these cases. If 
the wet dressing cannot be kept properly applied, a 10 per cent, oint- 
ment of boric acid, applied twice a day, will be found of considerable 
service in hastening the closure of the wound. The ointment should be 
smeared freely on gauze or clean linen and held in position by a properly 
applied bandage. In young children the ulcers are often most ob- 
stinate. In a few instances I have known them to continue from 
eight to ten weeks. In cases in which the healing has been particularly 
slow, the familiar dressing of balsam of Peru (5 per cent.) in castor oil, 
applied twice daily on a pad of several thicknesses of gauze and covered 
with oiled silk, has appeared to hasten the granulation. Unhealthy 
granulations may have to be curetted before the dressing is applied. 

DAYS TO GO OUT-OF-DOORS; INDOOR AIRING 

Physicians are frequently consulted as to the age when, and the 
conditions under which, it is permissible to take the baby out-of-doors. 
To answer this, the place in which the child lives, the season of the 
year, and the age and condition of the patient must be taken into 
consideration. 

A child, regardless of the age, should never be taken out in inclem- 
ent weather. If under one year, he should not go out if the tempera- 
ture is below 20°F. During the midday heat of summer the baby is 
better off in the largest and coolest room in the house or on a shady 
veranda. On very windy days the young infant should not go out; 
neither should he go out when the snow is melting in large quantities. 
When going out, on account of unfavorable conditions of the weather, is 
prevented, there should, however, be no lack of fresh air — the child 
should be given an indoor airing, dressed as for the daily outing. All 
the windows of the nursery or some other large, sunny room should be 
opened on one side of the room only. The doors should be closed, so 
that currents of air are avoided. The child should then be placed in his 
carriage, suitably covered, and left in the open room all day, except when 
he Ib fed and ''changed." Here he receives all that is good from out- 
doors and avoids much that is objectionable outside, in the forms of 
dust and moisture. 

This method will be found very useful in caring for ''winter babies^' 
— ^those born during the late fall or winter months. The indoor airing 
may be given for a week or more, before the infant is taken out. By 
this means the child may be gradually accustomed to a change of tem- 
perature from that of the average living-room to that out-of-doors, and 
will not be harmed when finally taken out. After an illness, further- 
more, indoor airing will afford an earlier means of returning to the 
daily outing. This indoor method of giving a child fresh air will be 
found useful with very delicate children also, who, by reason of their 



INSTRUCTIONS FOR THE SUMMER 763 

condition, may be unable to go out, during the winter months, for 
several weeks at a time. Few days during the winter are too cold or 
too stormy for the indoor airing. 

INSTRUCTIONS FOR THE SUMMER 

In addition to advising parents as to a selection of a summer resort 
for the family, I advise the mother as to the particular care of the child 
during the summer, whether he is to remain in town or go to the coun- 
try. During the months preceding the heated term every mother 
whose infant is under my care is made aware of the dangers of the 
next few months, and means are suggested, and written directions 
are given, as to how to pass through the summer with the greatest 
security. 

Selection of Milk. — The mother is told what market milks are the 
best. She is told that the milk must be kept on ice, with ice surround- 
ing the bottle, from the time of its dehvery until it is given to the 
child, except, of course, during the time spent in its special preparation. 

Reduction of Food Strength. — During the hot months in the city 
the child 's digestive capacity is not equal to that of the colder months. 
Children who remain in the city are given weaker milk mixtures, in 
which the fat and proteid are reduced from 15 to 25 per cent., the sugar 
remaining the same. The infant may not gain very much in weight, 
but on a reduced diet he is much more apt to pass through the summer 
without intestinal disorders, and there is abundant opportunity for 
him to gain later on. 

Clothing. — Mothers are instructed as to the amount of clothing 
required. They are told that a napkin, a muslin slip, a loose-mesh 
knitted band, are all that are required on very hot days. 

Water to Drink. — Bathing. — They are instructed to give the infant 
frequent drinks of boiled water between feedings, and if he suffers 
much from the heat, as shown by prickly heat and restlessness, to 
give him two or three spongings daily with a cool solution of bicar- 
bonate of soda, one teaspoonful to a pint of water. 

Withdrawal of Milk. — It is made very plain that vomiting or a 
green, undigested stool is a danger-signal which always means that the 
milk must be withheld for twenty-four hours or longer whether the 
child is nursed or bottle-fed, and that either barley-water or one of the 
other carbohydrate gruels (p. 70) must be substituted until such time 
as the stools improve or the vomiting ceases. This is one of the most 
important life-saving measures the physician can teach the mother. 
An immense majority of the intestinal diseases of summer, which de- 
troy thousands of lives yearly, have their origin in a neglected acute 
indigestion and diarrhea, which if properly managed means a slight 
illness of but a day or two. It is further impressed upon the mothers 
that upon resuming milk diet it must be given at first greatly reduced 
in strength, and then gradually increased until food of the previous 
strength is given. Beginning with one-half ounce of skimmed milk 



764 THE PRACTICE OF PEDIATRICS 

in each feeding, by watching effects upon the temperature and the 
stools, an increase of perhaps one-half ounce may be made each day. 

How to Obtain Safe Milk. — I have experienced not a little trouble 
in the past in securing safe milk for infants who were removed at a 
considerable distance from the depots of the better class of dairies that 
supply certified milk. The average farmer is notoriously careless in 
the handling of milk, and in the country districts, where the milk- 
supply should be the best, it is often as bad as can well be imagined. 
In remote country districts, where the milk is furnished by the farmer, 
a special arrangement is made, by which he agrees that the cow's 
belly, udders, and teats shall be wiped off with a damp cloth before 
milking; that the milker's hands shall be washed before milking; that 
the few jets of the foremilk shall be thrown away; and that as soon as 
the milk is drawn it shall be strained through sterilized absorbent 
cotton into a quart milk bottle, suitably corked, and placed in a pail of 
cracked ice. The cracked ice and the absorbent cotton are, of course, 
furnished by the consumer. For the extra trouble the farmer receives 
from 15 to 20 cents a quart for the milk. At one resort three babies 
were supplied in this way, by one small producer, with a comparatively 
safe milk. The improved milk-pail with a narrow opening insures a 
much cleaner milk, as it offers much less opportunity for droppings to 
fall into it during the milking than does the old-style pail. 

For those who have country homes and who can control their milk- 
supply the above precautions may be carried out to the letter. By 
such careful control of the home product, and by the use of milk from 
those dairies only which observe the above precautions, the acute 
digestive disorders of summer among my patients are rendered very 
unusual. These precautions, with the knowledge of the mother or 
nurse as to what to do at the first sign of a digestive disorder, will reduce 
the number of the so-called summer diarrhea cases to a very insignifi- 
cant figure. 

Among outpatients in large cities who have to use other milk and 
milk less clean, summer diarrhea must prevail. Among these, however, 
the death-rate may be remarkably reduced through the education of 
the mothers. At the outpatient department at the Babies' Hospital 
dispensary, where there is a clientele of fairly intelligent mothers who 
have been coming to us for years, there is a very low death-rate from 
summer diarrhea. By pamphlets of instructions as given below, and 
by showing these mothers that we have a personal interest in their 
children, we gain their confidence. They believe what we tell them, 
and, as a result, we repeatedly have children brought to us well along 
the road to recovery. 

For example, a child had developed diarrhea; he had been given a dose of castor 
oil, his milk was stopped and barley-water or rice-water given. 

The mothers are further told that it is never a good thing for a 
baby to have diarrhea ; that a diarrhea is never without dangers ; that 
an infant who has frequent attacks of indigestion during the cooler 
months is very sure to develop diarrhea during the hot months, and that 



INSTRUCTIONS FOR THE SUMMER 765 

the safest means of keeping a baby well in the summer is to keep him 
well all the year round. 

Rules for the Care of Dispensary Infants and Young Chil- 
dren During the Summer 

1. Clothing. — During the very hot days the baby should wear a 
napkin, a thin gauze shirt, and a thin muslin slip. An abdominal binder 
made of thin material, and loosely applied, may be worn until the 
child is six months of age. After this age the binder is not necessary. 

2. Bathing. — Every child should have one tub-bath daily. On 
very warm days from two to four ten-minute spongings with cool soda 
water (one teaspoonful of bicarbonate of soda to a pint of water) will 
greatly add to the child 's comfort. 

3. Fresh Air. — Fresh air is of vital importance. Leave the windows 
open. Keep the child in the open air when possible. Avoid the sun. 
Select the shady side of the street and the shade in the parks. 

4. Sleep. — Sleep is very necessary for growing children. A noon- 
day nap of at least two hours should be insisted upon until the child is 
four years of age. 

5. Soiled Napkins. — Soiled napkins should be placed in some 
covered receptacle containing water, and washed at the earliest 
opportunity. 

6. Drinking-water. — Boil one quart of water every morning. Put 
it into a clean bottle. Keep the bottle in a cool place. Give the water 
between the feedings — as much as the child will take. 

7. Breast-feeding. — The mother should wash the nipple with plain 
cold water before each nursing. She should be very careful as to her 
diet and habits of life. Her bowels should move once a day. Con- 
stipation in the mother produces illness in the child. She should have 
three plain, well-cooked meals daily, consisting largely of milk, meat, 
vegetables, and cereals. Beer and tea are often harmful. A large 
quantity, a couple of pints or more daily of either is positively 
objectionable. 

From birth to the third month: The baby should be nursed at three - 
hour intervals during the day. Seven nursings in twenty-four hours, 
with only one nursing between 10.30 p. m. and 6 a. m. 

Third to sixth month : The nursings should be at three-hour intervals 
during the day; 6 nursings in twenty-four hours; no night feeding. 

Sixth to twelfth month : The child now takes a larger quantity at each 
feeding. He should be nursed at four -hour intervals; 5 nursings in 
twenty-four hours. 

8. Bottle-feeding. — The bottle should be thoroughly cleansed with 
borax and hot water (one teaspoonful of borax to a pint of water) and 
boiled before using. The nipple should be turned inside out, and 
scrubbed with a brush, using hot borax water. The brush should be 
used for no other purpose. There should be three or four sets of bottles 
and nipples. The bottles and nipples should rest in plain boiled water 



766 THE PRACTICE OF PEDIATRICS 

until wanted. Never use grocery milk. Use only bottled milk which 
is delivered every morning. The milk should be boiled for five minutes 
immediately after receiving. The feeding hours are the same as in 
breast-feeding. Children of the same age vary greatly as to the 
strength and amount of food required. Food, when prepared, should 
be poured into a covered glass fruit-jar and kept on the ice. For the 
average baby the following mixtures will be found useful: 

For a child under three months of age: Nine ounces of milk, 27 ounces 
of boiled water, 4 teaspoonfuls of granulated sugar. Feed from 3 to 4 
ounces at three-hour intervals — 7 feedings in twenty-four hours. 

Third to sixth month: Eighteen ounces of milk, 30 ounces of barley- 
water, 6 teaspoonfuls of sugar. Feed 5 to 6 ounces at three-hour 
intervals — 6 feedings in twenty-four hours. No night-feeding. 

Barley-water is prepared by boihng a tablespoonful of Robinson 's 
barley flour or Cereo Co.'s barley flour in one pint of water for twenty 
minutes; strain and add water to make one pint. 

Sixth to ninth month: Twenty-four ounces of milk, 24 ounces of 
barley-water, 6 teaspoonfuls of granulated sugar. Feed 7 to 8 ounces 
at four -hour intervals — 5 feedings in twenty-four hours. 

Ninth to twelfth month: Thirty-eight ounces of milk, 12 ounces of 
barley-water, 6 teaspoonfuls of granulated sugar. Feed 7 to 9 ounces 
at four -hour intervals — 5 feedings in twenty -four hours. 

9. Condensed Milk. — When the mother cannot afford to buy bottled 
"milk, when she has no ice-chest or cannot afford to buy ice, she should 
not attempt cow's milk feeding. Canned condensed milk should be 
used as a substitute during the hot months only. The can, when 
opened, should be kept in the coolest place in the apartment, care- 
fully wrapped in clean white paper. The feeding hours are the same 
as for fresh cow's milk. 

Under three months of age: One-half to 2 teaspoonfuls condensed 
milk; barley-water No. 1 (see formulary, p. 70), 2 to 4 ounces. 

Third to sixth month: Condensed milk, 2 to 3 teaspoonfuls; barley- 
water, 4 to 6 ounces. 

Sixth to ninth month: Condensed milk, 3 to 4 teaspoonfuls; barley- 
water, 6 to 8 ounces. 

Ninth to twelfth month: Condensed milk, 4 to 5 teaspoonfuls; barley- 
water, 8 to 9 ounces. 

10. Feeding After One Year of Age. — All children should be weaned 
at the age of twelve months unless other orders are given by a physi- 
cian. The bottle-fed, also, at this age require more than milk and 
cereal water. During the second year children are almost invariably 
badly fed. 

Four meals a day should be given at the same hours every day. 
The mother will select suitable meals from the following articles: soft- 
boiled egg; scraped rare beef; strained broth of beef, mutton, or 
chicken with stale bread broken into it; toast and butter; stale bread 
and butter; toast and milk; stale bread and milk; oatmeal (cooked three 
hours) and milk; hominy (cooked three hours) and milk; cornmeal 



THE EXERCISE PEN 



767 



(cooked two hours) and milk; farina (cooked one hour) and milk. The 
milk used must be boiled during the hot weather. 

11. Summer Diarrhea. — When the baby has loose, green passages 
he is sick and needs medical attention. The disease is frequently mild 
at the beginning. There may be no fever and the child may show no 
signs of illness other than the diarrhea. Such a baby oftentimes, with 
milk-feeding continued, becomes dangerously, if not fatally, ill in a very 
few hours. The simplest cases of vomiting and diarrhea during the 
summer must never be neglected. A baby sick in this way should be 
given two teaspoonfuls of castor oil. Stop the milk at once. Give 
only barley-water or rice-water until the child can be taken to the fam- 
ily physician or to a dispensary. With slight variations the above 
rules may be made to apply to many outside of the dispensary class. 



THE EXERCISE PEN 

In another chapter, in speaking of "colds," and how children are 
exposed to the influences which may bring about what is known as a 




The exercise pen. 



"cold," the custom of allowing a child to sit on the floor and play at 
all seasons of the year is referred to as a most frequent means of 
exposure. There is always a current of air near the floor, as one 
readily discovers by resting his hand on the floor on a cold winter day; 
further, the floor of the average house is naturally the most unclean 
part of the dwelling. Here dust gathers and dirt from the street 
collects as it is brought in on the feet of older members of the family. 
On this necessarily unclean floor the young child is permitted to spend 



768 THE PRACTICE OF PEDIATRICS 

a considerable portion of his waking hours. It can readily be seen 
that countless numbers of bacteria may be transferred, through the 
medium of the hands, from the floor to the child 's mouth. Rugs and 
pillows, which are sometimes used, while cleaner than the floor, are of 
little assistance in preventing drafts. 

Exercise is very necessary for the child's proper growth and de- 
velopment. He must have an opportunity and place in which to creep, 
walk and run. In order that he may have these advantages and not 
be subjected to unfavorable influences, I have found the exercise pen 
(Fig. 112) of the greatest service. After being bathed, dressed, and fed 
the child is placed in the pen, on a rug or quilt. Toys are given him 
and the door is closed. He cannot come in contact with the stove, he 
cannot roll downstairs, and he is in no danger from the rough play of 
older children. He is given an opportunity for active exercise without 
a possible chance of injury. 

The pen can be made of any size, but the usual size is 4 feet square. 
It can be made of any light-weight wood, pine generally being used. 
The legs of the pen should be at least 12 inches long, bringing it well off 
the floor. The pen is so constructed that it may readily be taken apart 
and put together again, iron tenon hooks and iron mortices being used 
to hold the parts together. The floor may be made of any thin material. 
One-half inch pine boards nailed together, or papier-mache supported 
by narrow strips of board, may be used. The floor is supported by 
strips of board about one-half by two inches, which are fastened to the 
inner sides of the end-pieces. The pen is best placed in the corner of 
the nursery or the living room. Its size may be determined entirely 
by the size of the room. During warm weather in the country the pen 
may often be used out-of-doors. 

SUMMER RESORTS 

Where to take a baby for the hot months of the year is a vexed 
question which is raised in many city households every year, and it 
is one concerning which the physician is frequently called upon for 
advice. Several years of observation of a great many New York city 
children who have spent the summer out of town have led me to the 
following conclusions: 

First, the most desirable summer outing is to spend the first half of 
the season at the seashore, the remainder inland, preferably in the 
mountains. 

Second, the next place in order of desirability is inland, preferably 
the mountains, for the entire summer. 

Third, the least desirable is the seashore for the entire summer. 

It is not to be understood that many children will not do well if 
kept at the seashore throughout the hot months. Some, indeed, im- 
prove most satisfactorily, but among my own patients I have repeat- 
edly been impressed with the disadvantages of a too prolonged stay at 
the seashore. If kept there during August, infants are apt to show 



FOREIGN BODIES SWALLOWED 769 

signs of lassitude, and while not ill, they do not return to the city in the 
autumn with the vigor, appetite, and general robustness which charac- 
terize those from the hills and mountains. It must be remembered 
that only New York city children are referred to . Children whose home 
is a seaport thrive best when given the benefit of a complete change to 
the dry, invigorating air inland. Children with catarrhal tendencies, 
bronchitis, or adenoids, before or following operation, and children who 
have had attacks of rheumatism or who show rheumatic tendencies, 
should not go to the seashore, wherever their residence. For an inland 
resort, the mountains, by which we understand an elevation of 1500 to 
2000 feet, are not always necessary. The place selected, however, 
should be at an elevation at of least 600 feet. For cases of chronic 
bronchitis and rheumatism a soil of sand or gravel is best, and the 
sleeping-room of the child should always be above the ground floor. 
Other points to be considered in connection with the summer outing 
are the kitchen facilities, which must be ample. Often the larger hotels 
refuse the right of way to the kitchen. I find that in this respect much 




Fig. 113. — Small watch in the esophagus. 

more liberty is given in the smaller hotels and boarding-houses. The 
proper preparation of the child's food in the cramped quarters of sleep- 
ing-rooms is not impossible, but it is often difficult and always objec- 
tionable; therefore, if a cottage is available, it will be greatly to the child's 
advantage. Before selecting a home for the summer, the drainage and 
the source and quality of the milk-supply should receive the most care- 
ful attention. Country well-water or spring- water should invariably 
be boiled before using. 

FOREIGN BODIES SWALLOWED 

Every practitioner who has to do with children has had occasion to 
soothe alarmed parents because of unusual substances swallowed by 
the child. As a rule, the foreign bodies pass readily into the stomach, 
and in due course of time pass through the natural channels. 
49 



770 THE PRACTICE OF PEDIATRICS 

Illustrative Cases. — The father of an eighteen-months-old patient lost a diamond 
four-leaf clover tie-pin, and the whereabouts of the pin was not known until the 
child passed it by the bowel. 

The patient of a colleague passed an open safety-pin. 

The accompanying cut (Fig. 113) demonstrates the possible dangers of swallow- 
ing foreign objects. A small watch disappeared from the neck of a girl four years 
of age. It was assumed that it was swallowed, and the discharges were examined 
daily. The child took the usual diet without inconvenience, and it was assumed 
that the watch had passed into the stomach. After five days it was decided to 
locate the watch or at least determine if it was in the child's digestive tract. An 
a;-ray examination located the object as shown. A surprising feature in this case 
was the passage of the food alongside the watch. ^ Without the x-tslj the case would 
probably have been fatal, through the formation of a perforating ulcer of the 
esophagus. The patient was placed on her back with the head over the side of a 
table, to put the mouth and esophagus on a plane. By means of a ''penny- 
catcher" Dr. Robert Abbe, with some difficulty, succeeded in removing the 
watch. 

It is surprising what large and apparently dangerous objects will 
pass through the entire gastro-intestinal tract without harm. The 
danger lies in the object becoming fastened in some portion of the intes- 
tine and thereby producing ulceration and perforation. 

Active laxatives should not be employed in treating children who 
have swallowed foreign substances. Milk, bread-stuffs, and cereal 
foods that will make a large fecal mass should be given with the hope of 
carrying along the object. I have seen a small lead-pencil delayed for 
two weeks and passed without harm. 

The a;-ray should be used, repeatedly if necessary, in all cases in 
which there is a delay in the passage of swallowed foreign objects. 



XX. THERAPEUTIC MEASURES 

THERAPEUTICS IN CHILDREN 

It has been my object, in this work, to present as clear and detailed 
a description of the management of the illnesses of infancy and child- 
hood as space would permit, with a view to a better understanding of 
pediatric therapeutics. 

If I were asked what I considered an important requisite for the 
successful practice of pediatrics, I would answer: The education of the 
mother. It is impossible to do even fairly good work in treating dis- 
eases of children without proper home cooperation. A direction is 
never followed out as well as when the reason for it is properly under- 
stood. 

Many of our beneficial results are due to the therapeutic influences 
of remedies outside of the realm of drugs. Thus, diet, fresh air, cold, 
heat, massage, electricity, climate — all are important therapeutic 
agents in the diseases of children. Successful therapy applied to chil- 
dren involves an understanding and a knowledge of detail greater, per- 
haps, than in any other line of medical work. It not infrequently is an 
absence of such knowledge on the part of medical men which explains 
a great deal of the therapeutic doubt existing at the present time. 
Therapeutic nihilism, as far as pediatrics is concerned, means ignor- 
ance and incompetency. The time when the physician can make a 
diagnosis and cease from interest in the treatment of the case is past. 
One of two things happens in the absence of interest or ability on the 
part of the physician. The faith of humanity in curative agents is 
remarkable, and when the desired end is not reached by the first phy- 
sician, some other physician is called; and when he fails, the next 
resort usually is the charlatan and the proprietary and patent 
medicines. 

The prosperity of the irregular schools of various cults and ''sciences" 
supposedly healing in character, and the consumption by the people of 
millions of dollars' worth of useless proprietary and patent drugs, are 
to be attributed in a large degree to an indifferent application of ther- 
apeutic measures on the part of otherwise well-qualified medical men. 
A few great teachers of medicine, by precept and example, have done 
an incalculable amount of harm in their attitude toward therapeutics. 
Because they were, or are, unable successfully to treat disease, they 
assume that it cannot be done. Thus, therapeutic doubt, using the 
term therapeutics in the broad sense, has been in the past boasted of by 
men considered clever. Text-books on pediatrics are not without fault 
in encouraging careless practice, with necessarily an absence of favor- 
able results, especially when they state that ''treatment is along sup- 

771 



772 THE PRACTICE OF PEDIATRICS 

portive lines." What constitutes '^ supportive lines" in a given case? 
How is the practitioner to know the author's mind? Or, again, per- 
haps it is stated that ''free stimulation" is necessary. Stimulation 
how, when, why, and by what means is what must be known, in order 
to achieve satisfactory results. "Treatment according to the indica- 
tions of the case" does not help a puzzled physician to any great extent. 
''Treatment along the same lines as in adults" adds no illumination 
when a desperately sick child is the patient, and moreover is faulty 
teaching, for the reason that the treatment in such instances should 
never be the same as in adults. An infant or young child should never 
be treated the same as an adult, either by drugs or other measures, un- 
less we wish more thoroughly to convince ourselves of the uselessness 
of therapeutic measures. 

In order to practise therapeutics successfully in children the meth- 
ods of the physician must be flexible and adaptable. Children vary 
greatly in their physical and mental equipment much more than do 
adults. The practice of pediatrics is necessarily difficult, for every 
case has to be studied from its own standpoint. The physician who 
invariably treats all his cases alike will never do the highest class of 
work with children. The man, for example, who feeds all his difiicult 
feeding cases after one rule or pattern will be sure to have some other 
practitioner get his failures, which will not be few. A source of dis- 
appointment to physicians, particularly in the treatment of young 
infants and children, is in the disorders of nutrition. A tremendous 
amount of patience is required in dealing with such cases, and the ab- 
sence of prompt results is one of the difficult features he has to contend 
with in his relations with the family. There is, further, a distinction 
to be made as to what constitutes good results. If the infant develops 
into a strong child, we may chronicle our results as satisfactory even 
though a year was required before the condition of the patient was 
satisfactory. To cause a malnutrition baby weighing only eight 
pounds at six months, with marked milk incapacity, to show rapid 
growth by any method of artificial feeding is unusual, and our results 
are good if he gains but little during the first few weeks. Chronic 
colitis, tardy malnutrition, or nephritis may require months and years 
for correcting and yet furnish satisfactory results. 

In therapeutics in infants and children, particularly as regards the 
use of drugs, two points are to be kept in mind — the benefit hoped for 
and the possible harm that may result. A great deal of judgment must 
be used in the selection of remedies and the means of using them, lest 
our best intentions result disadvantageously to the patient. Thus, in 
bronchitis and in bronchopneumonia the ammonium salts are often 
given in combination with heavy syrups, such as tolu and wild cherry, 
both possessing little or no value as expectorants, but having the prop- 
erty of interfering seriously with the patient's digestion. Doubtless 
alcohol used indiscriminately is, on the whole, productive of more harm 
than benefit, largely through disturbing the digestion. Digitalis, the 
salicylates, and the potassium and sodium salts are all to be used with 



THE THERAPEUTIC VALUE OF CLIMATE 773 

judgment as to method and time of administration or they will do more 
harm than good. A point never to be lost sight of in the treatment of 
diseases of children is the desirability of keeping the gastro-enteric 
tract in the best possible condition. In children there are other factors 
also that bear upon the case that tend toward good or evil. The most 
careful diet, and the best selected medication are of little value if the 
patient is overclad, kept in a superheated room with anxious, often- 
times nervously exhausted persons in constant attendance, with the 
disturbance to the patient which such attendance entails. However, 
it must be remembered that absence of proper detail and good judg- 
ment with resulting failures is no argument against the value of thera- 
peutic measures, although it often furnishes the evidence upon which 
the argument is based. Much may be accomplished, by means of 
prophylaxis, in lowering the mortality in children under five years of age. 
In this the educated mother's aid is invaluable. She will lay aside preju- 
dices and unfavorable family influences, when a physician's direction 
appeals to her reason. Marasmus, malnutrition, and the intestinal 
diseases of summer, w^hich directly or indirectly are the cause of 
thousands of deaths yearly, are to a large degree preventable if the 
right step is taken at the right time, through the early appreciation of 
danger-signals on the part of both the physician and the mother. 

THE THERAPEUTIC VALUE OF CLIMATE 

That climate is a valuable therapeutic measure in the treatment of 
diseases in children is a well-recognized fact. To my mind an impor- 
tant advantage of a change of climate is that it means more air and better 
air. When patients go to a resort for climatic purposes it is usually at 
no inconsiderable expense, and they are therefore pretty likely to avail 
themselves of advantages. The same amount of air oftentimes could 
be furnished at home if the family cooperation always could be secured. 
By the use of the window-board, the roof-garden, and the indoor airing 
we can to a considerable degree make a climate of our own. Neverthe- 
less, in the majority of families the open-air treatment cannot be carried 
out successfully; therefore, the best interests of the patients are secured 
when they are sent away from home. There are conditions also in 
which such means as those just mentioned do not apply even if they are 
carried out. We can give children warm air, and regulate the tempera- 
ture of the air in the winter; but if they live in any of our coast towns or 
villages, we cannot give them cool, dry air in summer. Children who 
can be removed from a large city to the country, inland, for the summer, 
are invariably benefited, not only as regards their food capacity and 
the ordinary influences of open-air life, but they acquire also greater 
powers of resistance, and are thus less liable to attacks from acute in- 
testinal diseases. (See Summer Resorts, p. 768.) 

Pneumonia, Pertussis, and Grip. — During the colder months New 
York City children who are convalescing from pneumonia, pertussis, or 
any prolonged illness which has greatly reduced them, will make a much 



774 THE PRACTICE OF PEDIATRICS 

more rapid recovery when removed to Lakewood or Atlantic City, 
where open-air Hfe is more easily secured than at home. 

Malnutrition and Digestion Disorders. — Infants and children suf- 
fering from chronic digestive disorders, marasmus, and malnutrition, 
who are given the advantages of climate or open-air methods either in 
the home (p. 762) or by a change of residence, invariably make a more 
rapid recovery than do those deprived of good air because of a lack of 
appreciation of its value, or through fear of the child's taking cold. 

Nephritis. — Again, there are diseases in children in which the 
sudden change of temperature, affecting the peripheral circulation, may 
be decidedly harmful. Such conditions exist in slow convalescence 
from acute nephritis, and also in chronic nephritis. These cases re- 
quire an equable climate, with a permissible outdoor life, such as is 
furnished during our colder months by Florida and Lower California. 

Asthma. — My experiences as to the effects of climate in asthma 
have been contradictory. As a rule, cold climates and high altitudes, 
such as are offered by the Adirondacks, increase the asthma, particu- 
larly if emphysema is also present. Nevertheless, I have seen patients 
who were comfortable only when living under such climatic conditions. 
From November 1st to May 1st the best results have been effected in 
children by a change of residence from the cold and changeable weather 
of the Middle and Eastern States to Lower California or Florida. 
Residence at the seashore has not been helpful to my patients. Older 
children whose parents can afford it should be sent to a boarding- 
school, or to some other institution of learning, located where the climate 
is such as to guarantee freedom from attacks. 

Tuberculosis. — The best winter climate for a child with pulmonary 
tuberculosis is a dry chmate with a mild temperature, neither high nor 
low, but with sunshine in such abundance as to permit a daily outdoor 
life. Such a climate is found in southern New Mexico and Arizona. 
These places furnish conditions as near to the ideal as it is possible to 
approach. The Adirondacks, while furnishing a climate in winter 
which may be too severe for young children, answer well for those from 
eight to nine years of age in whom the disease is not far advanced. 

The Sanitarium. — The sanitarium treatment is always to be advised 
if the patient can afford it, or if it is otherwise available through 
charity. Its advantages rest in the fact of the discipline, the diet, the 
amount of exercise, the sleeping quarters, the clothing — in short, in all 
the details of the life, every one of which is important. In a sani- 
tarium all these matters are in the hands of those who are skilled in the 
management of the disease, and who direct each case according to in- , 
dividual needs. Resorts for tuberculosis cases are dangerous because 
of the possibilities of reinfection through the carelessness of others. In 
a well-managed sanitarium, however, regulations, regarding expectora- 
tion and the care of the sputum reduce this danger to a minimum. 
Sanitariums, however, are available to but few patients. Many have 
not the means necessary to a change of residence, and many others 
refuse to allow their children to be separated from them, both of which 



COUNTERIRRITANTS 775 

facts necessitate the home treatment of a great majority of the cases 
of pulmonary tuberculosis in young children in our larger cities. (See 
p. 364.) 

COUNTERIRRITANTS 

The counterirritants which I have found especially useful in pedi- 
atrics are mustard, capsicum, turpentine, camphor, chloroform, and 
iodin. 

Counterirritants are useful for two purposes — for the relief of pain 
and for the effect upon internal inflammation and congestion. Without 
doubt the diseased conditions in which counterirritation is of most 
value are the acute affections of the respiratory tract, such as bron- 
chitis, bronchopneumonia, and pleurisy. In acute bronchitis, when the 
terminal bronchi are involved, when there is cyanosis and rapid respira- 
tion, — from 60 to 80 per minute, — keeping the thorax enveloped in a 
mustard plaster, one part mustard to two of flour, until the skin is well 
reddened, will often reduce the respirations from 20 to 30 per minute, 
60 that the child, previously tossing and restless, will fall asleep. I have 
repeatedly been asked by nurses and mothers if the counterirritation 
could not be applied more frequently because of the apparent relief 
experienced by the patient. The applications may often be made with 
advantage at intervals of from four to six hours. They should be suffi- 
ciently strong to produce the desired redness of the skin in from five 
to ten minutes. This will usually be produced by using at first one 
part of mustard to two of flour. When the skin becomes tender from 
the repeated applications, but one part of mustard to five or six of the 
flour may be required. If the plaster is made too weak, it must remain 
long in contact with the skin, which thereby becomes macerated. 

Indications. — In Acute Inflammations of the Respiratory Tract. — 
When the bronchitis is of the asthmatic type, when there is decided 
bronchial spasm associated with bronchial catarrh, the counterirri- 
tation furnishes not a little relief. In this condition the whole thorax 
should be enveloped. In bronchopneumonia with considerable bron- 
chitis local applications of mustard over the involved areas are to be 
advised. The pain from pleuritic inflammation occurring independ- 
ently of, or at the onset of, lobar pneumonia, or developing during 
bronchopneumonia, may be considerably relieved by counterirritation. 
Here also the mustard should be used only over the painful area. When 
the pain is severe, equal parts of mustard and flour may be used for the 
first appHcation, if carefully watched, for a quick, sharp skin reaction 
should be produced. We have no evidence that there is any further 
action than that of a sedative retarding the inflammatory process 
within. The mother or nurse should always be cautioned to watch the 
skin under a counterirritant so that a blister shall not be produced. 

During the stage of engorgement and congestion of the bronchi, 
indicated by roughened or sonorous breathing with occasional sibilant 
rales, brisk counterirritation with mustard, or with camphorated oil 
and turpentine, appears to hasten the progress of the case toward 



776 THE PRACTICE OF PEDIATRICS 

recovery. That a respiratory disease is ever aborted by these methods, 
as claimed by some, is exceedingly doubtful. If the turpentine is used 
with the camphorated oil, the proportion should be one part of turpen- 
tine to two parts of the camphorated oil. The mixture should be well 
shaken before use and applied vigorously with the hand for ten minutes 
or until a distinct redness of the skin is produced. The mustard or the 
turpentine should be used in these cases at least three times a day. I 
know of no condition where it is necessary to blister a child's skin. 
Capsicum vaselin may be used in the same way and for the same pur- 
pose as the camphorated oil and turpentine. 

In Colic. — In severe colic a turpentine stupe will often furnish 
prompt relief, twenty drops of turpentine being mixed with one pint 
of water at 106°F. Into this a piece of flannel is dipped, then wrung 
sufficiently dry not to moisten the bed-clothing, and placed over the 
abdomen. Over this is placed a dry flannel and oiled silk so as to 
retain the heat and moisture. The appHcation may be renewed, if 
necessary, every fifteen or twenty minutes. 

In Pleurisy and Empyema. — When adhesions exist in emypema and 
pleurisy, while the pain is not acute, there is an uncomfortable drawing, 
dragging sensation in the chest which may persist for months. This 
has been relieved in a few of my cases by the tincture of iodin, U. S. P., 
painted over the painful parts every third or fourth night. 

In Intercostal Neuralgia. — In intercostal neuralgia, not infrequently 
seen in overworked school-girls, the repeated application, at intervals 
of three or four days, of tincture of iodin over the point of exit of the 
involved nerve will often be followed by complete cessation of the pain. 

Acute Articular Rheumatism. — For the pain in acute articular rheu- 
matism, chloroform liniment, U. S. P., may be applied to the joint, or, 
better, the solution of lead and opium, U. S. P., may be applied warm in 
old linen covered with oiled silk. 

COLD SPONGING IN FEVER 

Sponging with plain water, with salt water (a teaspoonful of salt to 
a pint of water), or with alcohol and water (one part alcohol to three 
parts water) is a means of reducing high temperature, with which every 
physician should be familiar. Cool sponging at 75°F. to 80°F., plain or 
medicated, is useful for two purposes: as a sedative and for the reduc- 
tion of fever. In measles or scarlet fever, although the temperature 
may not be high, the itching and burning of the skin prevent sleep, and 
the patient is very uncomfortable, but often, under such conditions, 
he will fall asleep during a careful sponging. In pneumonia, in typhoid 
fever, and in the intestinal disorders of summer, my nurses have a 
standing order to give a cold sponging for fifteen minutes at any time 
when, in their judgment, it may be indicated, not on account of the 
fever, but because of the sedative effect upon the patient. A sponging 
of ten to fifteen minutes three or four times a day with cool water (65° 
to 75°F.) will greatly help a baby, whether sick or well, to pass suc- 
cessfully through the hot days of summer. 



THE COOL PACK 777 

Sponging for fever, while possessing less antipyretic value than 
do other measures, such as a cold pack, for example, has the advantage 
in that it is safe and easy of application in the hands of the most un- 
skilled, and will be of assistance in influencing high temperature when 
other means are not available. In order not to antagonize or frighten 
timid children, it is often wise to begin with the water, whether plain or 
medicated, at 95°F., and reduce the temperature gradually by the 
addition of cold water or small pieces of ice. It is rarely necessary to 
go below 60°F., and usually the sponging should not be continued 
longer than thirty minutes. It is well to have an interval of rest — from 
thirty to ninety minutes — -between the spongings, as too frequent 
sponging, if resisted, may exhaust the patient. Every part of the body 
should be sponged in turn, but it is not necessary to expose the patient, 
who should be covered with a flannel blanket. When the process is 
completed, the skin should be briskly rubbed for a few minutes with a 
dry, rough towel. 

THE COOL PACK 

The cool pack, properly applied, is free from the slightest danger to 
the patient, and is the best means we possess with which to combat a 
continued high fever. The pack may be used freely and with as much 
success in treating the exanthemata as in dealing with typhoid fever or 
pneumonia. That cool water may not safely be applied to the skin of 
a child with scarlet fever is a fallacy which it is our duty to explain 
to mothers. 

The pack is prepared as follows, a rubber sheet being used to protect 
the bed-sheet: A large bath-towel, or some thick, soft, absorbent 
material, should be used. Muslin, linen, or any thin material does not 
answer so well. Slits are cut in the towel large enough for the arms to 
pass through, and the towel is folded around the body, enveloping only 
the trunk and buttocks (Fig. 114). The pack shoud not extend below 
the middle of the thighs. This leaves the arms and the greater part of 
the lower extremities free. A hot-water bag, carefully guarded, should 
be placed at the feet and the patient covered with a blanket of medium 
weight. The towel is moistened with water at 95°F. This higher 
temperature is necessary at first in order not to frighten the patient, 
as sudden cold is apt to do, and also to avoid shock. In two or three 
minutes the towel, without being removed, is again moistened with 
water at 90°F., later with water at 85°F., and still later, at 80°F. 
When the temperature of the water reaches 80°F., it should be main- 
tained at this point for half an hour, when the patient's temperature 
should again be taken. If at the beginning his temperature was 105°F. 
and now shows little or no reduction, the temperature of the water with 
which the towel is moistened should be reduced to 70°F., or, if necessary, 
even to GO^F. The child throughout, need not be disturbed, except to 
be turned from side to side in order to wet the towel with water of the 
desired temperature, this being one of the advantages of the pack over 
a tub-bath or sponging. The towel, or other material employed, should 



778 



THE PRACTICE OF PEDIATRICS 



not be used for more than six hours without being replaced by a 
fresh one. 

For the first hour or two in a pack the temperature of the patient 
should be taken every half -hour. When it is reduced to 102°F., the 
pack should be removed, for, if it is continued longer, too great a reduc- 
tion may take place. If the fever rises again rapidly to 105°F. or 
higher it is well to keep the patient in the pack continuously. The 
degree of cold necessary, in the individual case, to keep the temperature 
within safe limits will soon be learned. I recently kept in a pack for 
seventy-two hours a boy four years old with lobar pneumonia. In 
this case a continuous pack of 70°F. was required to keep the tempera- 
ture at 104:°F. or slightly lower. 

Another reason for frequently taking the temperature is that, early 
in the attack, we do not know how the fever will be affected by the con- 
tinued cool applications. In some children it is very readily influenced, 
and in such a case collapse might follow a very sudden reduction of the 




Fig. 114. — The cool pack. 

temperature. In cases readily controlled, the pack may be necessary 
for only one-half hour or an hour, at intervals of three or four hours. 
An ice-bag may with advantage be kept at the head when the child is 
in the pack. Suddenly enveloping the entire skin surface in a cold 
sheet at 70°F., as advocated by some writers, may increase the tem- 
perature and occasion grave symptoms of impending death, because of 
the sudden contraction of the superficial blood-vessels, which sends the 
blood to the viscera, producing congestion of the internal organs. 

BATHS 

The newly born child should be given, daily, a basin-bath with luke- 
warm, boiled water and Castile soap until the cord falls and the navel 
heals. When this has taken place, the tub-bath may be given. The 
temperature of the bath for the very young infant should not be below 
95°F. nor above 100°F. Very young children should not be kept in 
the water more than three minutes. After the third or fourth month 
a temperature of 90° to 95°F., is best, the child being kept in the water 
about five minutes. At this age I prefer to have the tub-bath given at 



BATHS 



779 




night, just before the child is put to bed. A basin-bath may be given 
in the morning. When the child is a year old and fairly vigorous, the 
temperature of the water at the beginning of the bath should be 90°F. 
This should gradually be reduced to 80°F. by the addition of cold water, 
the child being vigorously rubbed with the hand while in the water. 
The temperature of the room should be from 76°F to 80°F. during the 
bath, and windows and doors should be closed. When removed from 
the tub the baby should be dried quickly and 
thoroughly, and the folds of the skin should be well 
powdered. A sponge should never be used in any 
portion of the bathing process and should never be in- 
cluded in the nursery outfit. It is never clean after it 
has once been used. Some children have a dread of 
the bath, and cry frantically when placed in the 
water. This is due to fear, and may usually be over- 
come by placing a sheet over the tub and lowering 
the child on it into the water. 

The Cold Douche. — For " runabouts'' from two to 
three years old it may not be wise to use water below 
70°F., but many children over three years have the 
water applied in the form of a cold douche after the 
cleansing bath, during the entire twelve months, at the 
temperature at which it runs from the faucet. In 
winter, in New York houses, this ranges from 50° to 
60°F. 

In giving the cool douche the child should stand 
in warm water covering the ankles. The douche may 
be used in the form of a spray or shower, or the water 
may be applied by means of a sponge at the desired 
temperature. The head, if the shower or spraj^ is 
used, should be suitably protected by an oilskin or 
rubber bathing cap. 

After the cold douche there should be a vigorous 
friction of the skin with a rough towel. If there is 
not a quick reaction, if the skin does not become warm 
and glowing, warmer water should be used. So also 
with blueness of the extremities and "goose flesh," 
water less cold should be used, but the douche should 
not be discontinued. 

In the great majority of homes the bathing of the children can be 
carried on with greater convenience immediately before their bed-time. 
The child should receive the warm bath and the cool douche, and then, 
in night-clothes, a warm wrapper, and suitable foot covering, he should 
eat his supper. However, if this time is not convenient, he may be 
given the evening meal at 5.30 or 6.30, followed in one hour by the bath 
and bed. 

Tub -baths for Fever. — Place the child in water at a temperature of 
95°F. and reduce to 80°F. or 75°F. by the addition of ice or cold water. 



i 



Fig. 115.— Bath 
thermometer. 



780 THE PRACTICE OF PEDIATRICS 

The duration of the bath should not be more than ten minutes, constant 
friction being maintained during the entire process. 

Basin Bathing for Fever. — Add eight ounces of alcohol to a quart 
of water at a tempej-ature of 70°F. The child is stripped, covered with 
a flannel blanket, and the entire body sponged with this solution for 
ten or fifteen minutes. Drying the skin should not be practised. Al- 
low the alcohol and water to evaporate from the body surface, as by 
this means a greater reduction in the temperature will be affected. 

Either the tub-bath or the basin-bath may be used by the mother 
in case of sudden high fever — 104° to 105°F. — before the physician 
arrives. She should be so instructed. 

Bathing for Comfort in Hot Weather. — The basin-bath and tub- 
bath may also be used as a means of relief during very hot weather. 
One or two basin-baths a day, with a tub-bath at bed-time during this 
trying season, will give the child much relief, and help him to pass 
safely through. The very young feel the extreme heat most acutely, 
and endure it with difficulty. I know of nothing else that will give a 
restless, uncomfortable, heat-tormented child such a refreshing sleep 
as will a cool tub- or basin-bath. 

Mustard Bath. — A mustard bath is prepared by adding a heaping 
tablespoonful of mustard to six gallons of warm water. From five to 
ten minutes in the bath is all that is advisable to allow. The special 
use of the mustard bath is in the treatment of convulsions; it will be 
found useful also for nervous children who sleep badly. Two or 
three minutes in the mustard water, followed by a quick rubbing 
immediately before going to bed, are oftentimes all that will be re- 
quired to induce refreshing sleep. 

Brine Bath. — A brine bath — an even tablespoonful of salt to one 
gallon of water at a temperature of 95°F. — is of great service with very 
delicate, poorly nourished children. Its action is that of a tonic. If 
the child is thoroughly soaped and washed with plain water and then 
immersed in the brine bath, no further rubbing is necessary. The 
child should be kept in the bath for five or ten minutes, constant fric- 
tion being continued during the entire time. The brine bath is not 
applicable to children with intertrigo or eczema. 

Soda Bath. — The soda bath is of some service in cases of prickly 
heat, from which many children suffer during the summer. A table- 
spoonful of bicarbonate of soda should be added to each half gallon of 
water used. The temperature of the water should be that to which the 
child is accustomed. From two to four minutes in the water suffices. 
There should be little or no friction of the skin. The child should be 
dried with soft towels. 

Bran Bath. — The bran bath also is of service in prickly heat. One 
cup of bran is mixed with the water in the bath-tub and the same 
method employed as for the soda bath. 

Starch Bath. — The starch bath is also useful in prickly heat. One- 
half cupful of powdered laundry starch is mixed with the water in the 
bath-tub, and the same method employed as for the soda bath. 



UNPALATABLE AND NAUSEATING DRUGS 781 

Hot Bath. — The child is placed from three to five minutes in water 
which has been raised to a temperature of 105° or 110°F. Constant 
friction of the extremities is maintained during the bath. 

BATHING THE SICK 

There is a pronounced objection among many to bathing children 
when ill, particularly when they are suffering from respiratory diseases 
or from the exanthemata. The functions of the skin as an organ of 
excretion and elimination are most important, and it is absolutely nec- 
essary that, during illness, when the metabolic processes of the body 
are being carried on to an excessive degree, all the eliminating organs be 
kept in the best possible condition in order that they may the better do 
their work. Therefore to perform its functions properly the skin must 
receive proper attention, and there is no better means of stimulating it 
to a sharp reaction than bathing with weak salt water — a teaspoonful 
of salt to a gallon of water — at a temperature of 85° to 90°r., followed 
by a brisk rubbing. Every sick child should receive a sponge-bath 
at least once daily. It is the sudden contact of cold air with the moist 
skin which occurs sometimes in undressing a child, without the attend- 
ant reaction, that causes the shock, the ''cold," which is usually 
attributed to the bath. It is the temperature of the room in which the 
child is undressed, the careless method of bathing, and not the applica- 
tion of water, which cause the trouble. Even the danger of this ex- 
posure is greatly overestimated. In order to avoid every possible 
danger, however, the temperature of the room in which the sick or 
delicate child is bathed should be raised to 80°F. I have yet to know 
of a child who suffered from the effects of a bath properly given, and I 
know of hundreds who have suffered because of its absence. 

UNPALATABLE AND NAUSEATING DRUGS 

It is impossible to mention in detail all the drugs which might be 
included under this heading. Only those will be referred to which we 
are obliged to use almost daily in our work — drugs which are either un- 
pleasant to the taste or which may be badly borne by the stomach, or 
drugs combining both these disadvantages. How to administer certain 
drugs so that their use may be continued and yet not interfere with the 
digestive function is a question which deeply concerns those who may 
have children for their patients. The element of taste is a most impor- 
tant one to a child; therefore, when possible, drugs disagreeable to the 
taste should be given to children in tablet or pill form or in capsule. 
The continued use of a drug oftentimes depends upon its being made 
palatable. As a general rule, when pills, tablets, or capsules are given, 
one-half glass of water should be taken at the same time, in order to 
diminish any possible irritant effects upon the mucous membrane of 
the stomach. 

Salicylate of Soda. — Salicylate of soda is a drug disagreeable in taste 
and very liable to destroy the appetite and interfere with digestion. 



782 THE PRACTICE OF PEDIATRICS 

In acute rheumatism its use is invaluable, and we are obliged often- 
times to give it in large doses. It is best given after meals with one- 
half glass of milk. Fairly large doses at this time, well diluted, are 
better than more frequent smaller doses. This drug usually is better 
borne if given in solution with peppermint-water or with simple elixir 
diluted 50 per cent, with water; but the taste when thus given is only 
partially disguised, and being still very objectionable to many, may be 
prevented by the use of a capsule if the patient is old enough, care being 
taken to give a considerable amount of water or milk with each capsule. 

lodid of Potash. — This drug is indispensable and is one for which 
no other can be substituted. It is best given in solution. It is most 
disagreeable in taste and directly irritant to the mucous membrane 
of the stomach. Like salicylate of soda, it should be given after meals 
with one-half to one glass of water or milk. It is best given plain, as 
the saturated solution, which may be dropped into the milk. 

Bichlorid of Mercury. — This drug is usually given in such small 
doses that its irritant properties are but little felt. It is best prescribed 
in tablet form, dissolved in two teaspoonfuls of water and followed by 
a swallow of water. When possible, it should be given after feeding. 

Alcohol. — Alcohol is another drug which should be given well 
diluted, regardless of the form in which it is administered. It is best 
given with or after food, but it should always be given diluted with 
at least six parts of water, if whisky or brandy is used. 

Ipecac and Tartar Emetic. — Ipecac and tartar emetic, when em- 
ployed as expectorants, are best given with sugar of milk in powder 
or tablet form. They should never be given on an empty stomach. 
Two or three teaspoonfuls of water should precede their administration 
when they are not given within a reasonable time after feeding. In 
many children, when given without this precaution even in the usual 
doses, they will often decrease the appetite and the digestive capacity. 

The Ammonium Salts. — Carbonate of ammonia must always be 
given in solution and should always be well diluted with water. Mu- 
riate of ammonia may be used in tablet or powder form. Water or 
milk should precede the administration of either. One part of simple 
elixir with two parts of wat.er makes an agreeable combination. 

Oils. — Oils used for nutritive purposes should invariably be given 
after meals. Plain cod-liver oil or any of the preparations containing 
it should never be given on an empty stomach. 

Castor Oil. — Castor oil is best given when the stomach is empty. 
A much more prompt and satisfactory cathartic effect is thus produced. 
The oil may be given in soda-water or coffee, with orange-juice, or in 
peppermint-water. Older children sometimes take oil better plain, 
sandwiched between the two halves of a peppermint cream, first the 
candy, then the oil, followed by the remainder of the candy. If castor 
oil is vomited, it may be repeated in a few minutes, and often will then 
be retained. 

Creosote. — Creosote is most difficult of administration to many 
children. I usually prescribe the carbonate, which is ordered to be 



ALCOHOL 783 

dropped into one or two teaspoonfuls of wine after meals. It may 
also be given in soft capsules or in an emulsion. 

Quinin. — Quinin should be given in solution or in capsule. Quinin 
pills as they are sometimes made, with an insoluble coating, pass un- 
changed through the entire intestinal canal. For purposes of solution 
a most satisfactory menstruum is a preparation of yerba santa, known 
to the trade as Yerberzine (Lilly). The bisulphate should always be 
prescribed for children, for the reason that it may be given in complete 
solution without the addition of acid. 

Strychnin. — Strychnin, on account of its taste, is often strenuously 
objected to, and is, therefore, better given in tablet triturate form. If 
the tablet cannot be swallowed, it may be broken into small pieces (not 
powdered) and mixed with a teaspoonful of orange pulp or in a thick 
cereal jelly. 

Digitalis. — Digitalis, when the tincture or the infusion is used, 
should never be given when the stomach is empty. It should be ad- 
ministered after meals or the drinking of water or milk. There are few 
drugs that will so completely destroy a child's desire for food as the 
digitalis preparations when put into an empty stomach. 

Tincture of Muriate of Iron. — The tincture of muriate of iron should 
be given after meals, well diluted, in at least one-half glass of water. 
The child should take the medicine through a glass tube so as not to 
injure the teeth. Iron preparations generally should be given after 
meals, and in case the liquid preparations are used, they should be well 
diluted with water. 

ALCOHOL 

In its relation to children, alcohol, regardless of the form in which 
it is used, must always be considered as a drug and not as a beverage. 
It is occasionally of great service in diseases of children. Under cer- 
tain conditions it answers better than any other means of stimulation we 
possess. The fact that it is grossly misused does not in any way de- 
tract from its value in illness. It is too often given, chiefly for the 
reason that its use, in the form of whisky and brandy and wine, is ad- 
vocated in medical work in many of the ordinary ailments of childhood 
where really it is absolutely contraindicated. Its use, in my hands, 
has been that of a food and stimulant in very grave conditions, the 
duration of its usefulness being often completed in a day or two. 
When given to children for a prolonged period, even in moderate 
quantities, it invariably interferes with digestion and assimilation, and 
therefore does harm. It is very liable also to act as an additional 
irritant to the kidneys, which are prone to show inflammatory changes 
as a result of the systemic toxemia due to the disease. We have 
heart stimulants which are ordinarily as effective as alcohol and with- 
out its danger either to the stomach or the kidneys. 

It is my practice never to give alcohol early in an illness unless the 
onset is accompanied by profound prostration, but rather to hold this 
drug in reserve until it is absolutely necessary. Used in this way, it has 



784 THE PRACTICE OF PEDIATRICS 

been of much service in two conditions in which, in my opinion, 
nothing can replace it. I refer, first, to that time which may arise in 
any grave disease when the heart fails to respond to the usual stimula- 
tion, as in the crisis of lobar pneumonia and in the profound toxemia of 
scarlet fever or diphtheria. At such a time the powers of assimilation 
for most drugs as well as for food are reduced to a minimum. When 
food is rejected, or taken badly, when the usefulness of strychnin, 
strophanthus, musk, camphor, digitalis, and caffein has been exhausted, 
alcohol should be given and given in as large doses as may be required 
to produce the desired results. It is astonishing what large quantities 
of alcohol may be given without the slightest intoxicating effects in 
many such conditions. When given well diluted it is usually well 
borne and assimilated; it supports the heart, improves the respiration, 
and often will carry the patient through to a successful convalescence 
even when the outlook is very unpromising. As the system readily 
becomes accustomed to alcohol, it must be given in increasing doses. 
If it is begun early in the illness, it will have lost its stimulating 
effects by the time it is most needed. Brandy or whisky, well diluted, 
is the form in which it is generally used. 

The second condition in which alcohol is useful is in cases with 
greatly lowered vitality resulting from some severe illness, such as 
typhoid fever, enterocolitis, or pneumonia. If a child is suffering from 
shock bordering on collapse, or collapse with a subnormal temperature 
with all the vital powers at a low ebb, alcohol will do much to sustain 
him until he is able to assimilate easily digested or predigested foods. 
In such cases whisky, well diluted, — 1 part whisky to 6 parts of water, 
— given at intervals of two or three hours, will hasten recovery. If 
the child cannot swallow, the whisky may be given by gavage; if vom- 
ited, double the quantity, well diluted, may be given by the rectum. 
Its hypodermic use is infrequently resorted to chiefly for the reason 
that other remedies, such as strychnin and digitalis, are more effective 
than alcohol when so given. The doses vary from 5 drops to 3^^ dram 
every one or two hours, 12 to 24 doses in twenty-four hours, for a child 
one year of age. A child two years of age may be given 1 dram at in- 
tervals of one or two hours. The use of alcohol is attended with the 
least disturbance when it is given after the feedings. 

HEAT AS A THERAPEUTIC AGENT 

Heat has long been used as a therapeutic measure. For infants 
and children it has a wide range of usefulness, both as dry heat and 
when conveyed by the use of water as a vehicle. 

Moist Heat. — Heat, water-borne, is used as follows : 

In colic and indigestion and as a diuretic, internally. 

In acute gastritis, as a sedative, taken by sipping. 

In convulsions, idiopathic and uremic, by means of baths. 

In convulsions, idiopathic and uremic, as colon flushings, 105° to 
110°F. 

In colic, as a hot stupe applied to the abdomen. 



COLD AS A THERAPEUTIC AGENT 785 

In torticollis, as a hot compress to the neck. 

In sprains, as a hot compress to the joint or muscle. 

In acute articular rheumatism, as a hot compress to the joint. 

In retention of the urine, as a hot compress appHed to the lower 
abdomen and bladder. 

In suppression of the urine {acute nephritis), as a poultice or hot 
compress over the kidneys and in colon flushings, 105° to 110°F. 

In cerebrospinal meningitis, as a hot bath or hot compress to the 
trunk and lower extremities. 

In pleurisy, as a hot compress to the painful area. 

In acute angina, as a gargle. 

In conjunctivitis, as a hot compress. 

To hasten suppuration in an abscess, as a poultice or compress. 

In retropharyngeal abscess and in peritonsillitis (quinsy), as a throat 
douche. 

In earache, as a douche or by means of a hot-water bag. 

In toothache, by means of a hot-water bag, or as hot water held in 
the mouth. 

In facial neuralgia, by means of a hot-water bag. 

In prematurity and in lowered vitality or reduced temperature after 
disease, by hot-water bags or bottles. 

Dry Heat. — Dry heat is used in the following conditions: 

In prematurity, lowered vitality, or reduced temperature after disease, 
by means of the electrotherm. 

In suppression of the urine {acute nephritis), by the electrotherm or 
by hot air (p. 447). 

In using heat with children caution should be exercised as to the 
degree employed. Serious burning accidents have occurred by the 
use of hot-water bottles and hot compresses. When it is used very 
hot, the hot-water bottle should be guarded by wrapping it in flannel. 
Moist heat in the form of compresses, poultices, and stupes should 
always be tested by placing the vehicles against the face of the atten- 
dant. The adult hand will often bear a greater degree of heat than is 
safe to apply to the skin of an infant or young child. In using hot 
packs, hot-water bags, the electrotherm, or dry heat, generated by 
a lamp or other device, such as the Kilmer kettle, a thermometer 
should be placed between the child's clothing and the bed-cloth- 
ing. A temperature of 110°F. is the highest to use with children. 
When water is the vehicle, the patient must be most carefully watched 
and the application frequently renewed because of the rapid evapora- 
tion. A compress or poultice must not be allowed to get cool. A 
piece of flannel or oiled silk or rubber tissue over a hot compress will 
obviate the necessity for frequent changes. 

COLD AS A THERAPEUTIC AGENT 

In the treatment of children, cold is generally used in the form 
of compresses, baths, or packs, and is indicated in the following 
conditions : 
50 



786 THE PRACTICE OF PEDIATRICS 

In tonsillitis, acute 'pharyngitis, and headache, in the form of a cold 
compress. 

In meningitis and pyrexia, by means of the ice-bag or the cool coil. 

In appendicitis, by means of the ice-bag. 

In endocarditis and pericarditis, by means of the ice-bag. 

In fever, by means of baths, cold packs, sponging, and in older chil- 
dren, by colon flushings. (Not lower than 70°F. when used thus.) 

In adenitis and in threatened superficial abscess, by means of an ice- 
bag. 

In hysteric and neurotic children, as a spinal douche. 

In malnutrition in older children as a tonic, by means of a moderate 
cool spinal douche following a warm bath. 

For further details as to the application of cold in special diseases 
the reader is referred to the discussion of the diseases in question. 

BLOOD TRANSFUSION AND INTRAMUSCULAR INJECTION 

Blood transfusion* has been practised in some form since the dis- 
covery by Harvey of the circulation; and devices to accomplish the 
transfer of blood were employed by Folli, and des Gabets, a Benedic- 
tine nqionk as early as the middle of the seventeenth century. Authen- 
tic accounts moreover exist recording successful operations in trans- 
fusion by Richard Lower and by Jean Denys in the years 1666-1667, 
while in 1667 Denys and King successfully transfused blood from a 
sheep to a man by means of two cannulas united by a section of carotid 
artery taken from a horse or ox. As a means of injecting blood the 
syringe was employed by James Blundell in 1818. Later forms of 
apparatus were all modifications of a direct connecting mechanism of 
some sort such as that of Lower, or of a '^ conducting system" supple- 
mented by an "impellor" or syringe. 

During the past quarter of a century the practice of transfusion 
which for many years was held in disrepute because of fatalities (many 
of which were due to antagonistic action between the blood of donor 
and that of recipient), has been revived with remarkably good results 
and the technic has been simplified sufficiently to render the opera- 
tion relatively free from risk in ordinary hands. The successful but 
difficult methods of Carrel and Crile have now given place to the Linde- 
mann method of transfusion by the syringe and cannula system, and 
this procedure in turn has been improved upon by the modification of 
Ungerf which consists in the employment of a stopcock controlling a 
syringe which transfers the blood from donor to recipient, at the same 
time permitting the systematic flushing of the connected cannulse 
with saline solution from a second syringe which forms part of the 
apparatus. 

Most of the bad results ascribed to transfusion in the past have been 
due either to incompatibility of blood, i.e., "hemolysis or agglutination 

* Hooker and Satterlee in Johnson's "Operative Therapeuses, " vol. i, p. 337. 
t Jour. A. M. A., Ixiv, p. 582. 



BLOOD TRANSFUSION AND INTRAMUSCULAR INJECTION 787 

of the red blood cells of either donor or patient by the serum of the 
other," or to failure to select donors free from infectious disease capa- 
ble of transmission in the blood. Preliminary tests are, therefore 
always essential to exclude the possible occurrence of hemolysis and 
to insure the absence of such types of blood infection as syphilis and 
malaria. 

The indications for transfusion in children include severe secondary 
hemorrhages from whatever cause (whether typhoid fever or tonsil- 
lectomy), severe secondary anemia, the cause of which can be con- 
trolled, hemorrhagic disease of the new-born, purpura, and occasional 
cases of malnutrition or infectious disease. Intramuscular injections 
of blood from convalescent scarlet fever patients have thus been em- 
ployed by Park and Zingher in treating severe cases of this disease and 
with apparent good results. 

In the actual application of transfusion in a child's case, the external 
jugular vein or the median basilic is selected to receive the blood and 
the amount introduced is seldom over 7 ounoes. 

In hemorrhages of the newly-born the intra-muscular injection of 
blood has been successful in absolutely controlling the hemorrhage in 
4 cases. In each patient 1 ounce of blood was injected — 3^^ ounce into 
each buttock. 

The advantages of direct blood injection over transfusion are con- 
siderable; the technic, which consists only in extracting the blood 
from the vein of the donor and injecting it intra muscularly, can be 
carried out by any physician. Tests for agglutination and hemolysis 
are not required. 

Transfusion has been used in a child who developed a severe 
purpura after diphtheria. There were extensive hemorrhages under 
the skin and uncontrollable bleeding from the nose and gums. Six 
ounces of blood was transfused by Lindemann, using his own method. 
The bleeding promptly ceased and the child recovered. I am confident 
that the issue would have been fatal had transfusion not been promptly 
employed. 

A boy eight years of age developed severe influenza, double otitis 
media, double mastoid and sinus thrombosis of the right side, all of 
which were operated as the occasion arose. Recovery was proceeding 
slowly and after three weeks of a most exhausting illness lobar pneu- 
monia developed. It seemed that recovery was now impossible. The 
parents were advised that transfusion held out the only hope. Two 
transfusions were given by Lindemann, using his own method, with an 
interval of two days. At the first transfusion 8 ounces of blood was 
given; at the second, 6 ounces. The boy is perfectly well to-day, two 
years after the illness. I am confident that recovery would have been 
impossible without the transfusions. 

I have employed transfusion in 8 cases of extreme secondary anemia 
in infants (p. 404) with complete cure in 7 cases. One case showed 
no improvement. (For transfusion in acidosis see p. 715.) 



788 THE PRACTICE OF PEDIATRICS 

LAVAGE— STOMACH- WASHING 

To Seibert, of New York, is due the credit of first calling attention 
in this country to the value of stomach-washing. Its use was soon 
appreciated by pediatricians generally, and at the present time it is an 
indispensable therapeutic measure with those who are actively engaged 
in children's hospitals, in outpatient or in private work among children. 
In the vomiting of children, whether due to an acute gastro-enteric 
infection, chronic indigestion, or a subacute attack of chronic gastritis, 
it is equally valuable. The dangers of stomach-washing can be said to 
be practically nil. A colleague a few years ago, while washing the 
stomach of a child two years of age, turned away for a moment, when 
suddenly the struggling child disconnected the tube from the glass 
connecting-rod and swallowed the tube. Attempts at its removal 
through the bowel were unsuccessful; gastrostomy was performed, the 
tube removed, and the child recovered. This is the only accident of 
any kind I have ever known during stomach-washing. 

The Operation. — For lavage, the child is easiest handled when its 
arms are pinned to its sides by a towel passing around the body. It 
may rest on its back in a crib, or sit upright on the lap of the nurse or 
mother (Fig. 116). The clean left index-finger of the physician is 
placed upon the base of the patient's tongue. The tube, moistened 
with the fluid to be used in the washing, not with oil, is passed down over 
the base of the tongue into the esophagus. Passage of the tube into 
the larynx is practically impossible. I have washed the stomachs of 
many hundred children, and the introduction of the tube has never 
been attended with difficulty. When it has entered the esophagus, it 
should be passed rapidly into the stomach. At least nine inches of the 
tube will be required to reach the lower portion of the stomach. At 
first the child will cough, retch, and become red in the face, but this 
need cause no alarm. He will soon cry and begin to breathe regularly. 
When the tube is in position, the funnel should be held the length of 
the tube, two and one-half to three feet above the patient's body; the 
water, which should be first boiled, may then be poured into the funnel. 
At first the water may remain stationary in the funnel, owing to the 
pressure of air in the stomach and the straining of the child. When 
the child relaxes or the air escapes, being forced upward through the 
water, the water will pass rapidly into the stomach. 

The apparatus described under Gavage (p. 790, Fig. 117) is used. 
It should always be boiled before using. If much mucus is present, 
a 1 per cent, solution of boric acid or borax may be used. The amount 
introduced into the stomach at one time varies with the age of the 
child. For a baby of one week 1 ounce may be used ; at six weeks, 2 
ounces; at six months, from 4 to 6 ounces. It is rarely advisable to 
introduce more than 6 ounces at one time. The fluid is allowed to run 
into the stomach and is then siphoned out by lowering the funnel, the 
process being repeated until the fluid returns perfectly clear. From 
one to two pints of water may be necessary to complete the 
washing. 



LAVAGE STOMACH- WASHING 



789 



Indications. — It is rarely necessary to wash the stomach oftener 
than twice in twenty-four hours. Ordinarily, in the acute vomiting 
cases, one washing daily for four or five days will answer. In cases of 
chronic indigestion with regurgitation the washing will be needed less 
frequently — once a day, or once every second or third day. 

The following is frequently the history of a case of chronic indiges- 
tioij with vomiting: There has been, for several weeks, vomiting of 




Fig. 116. — Lavage. 

food and mucus, two or three times daily. The stomach has been 
washed, the child carefully dieted with a plain barley-water or a weak 
milk mixture, and no vomiting has occurred for perhaps twelve, twenty- 
four, thirty-six, or forty-eight hours, when the regurgitation or vomit- 
ing again commences as before. In such a case it will soon be learned 
how frequently the washings should be repeated in order to control the 
vomiting. 



790 THE PRACTICE OF PEDIATRICS 

Illustrative Case. — A recent case represents my management: A child six months 
old suffering from malnutrition had a history of persistent vomiting after each feed- 
ing. A greater part of the food taken was lost. What was not vomited was 
digested imperfectly, as was shown by the stools. The stomach was washed and a 
large quantity of thick mucus and curds removed. The child was given a barley- 
water diet. There was no vomiting for three feedings, and then only a small 
quantity of barley-water was thrown off. After three days, following daily wash- 
ings, the vomiting entirely subsided. The child was given a weak milk mixture, 
one-fifth milk and four-fifths barley-water, and no significant vomiting resulted. 
The food was carefully strengthened, and although in two weeks the vomiting had 
entirely ceased, the washings were continued at intervals of two or three days for 
a month until the water siphoned out was free from mucus. 

In severe cases of chronic indigestion the washings at intervals of 
two or three days may be continued with advantage for several months. 
It must be remembered that in these chronic cases of indigestion the 
patient is ill through abuse of the stomach — usually because too strong 
food has been given, or too much of a suitable food has been given at 
too frequent intervals. As important, then, as the stomach-washing, 
is the giving of food suited to the child's digestive capacity. Lavage 
is of little service if the bad feeding continues. 

The field of usefulness of lavage is not entirely confined to vomiting 
cases. Children with indifferent appetite and limited food capacity, 
but without vomiting, are often greatly benefited by the treatment. 
A story frequently heard in our consulting room is as follows : Food is 
taken without relish. The child must be coaxed to eat. There is loss 
of appetite, usually the result of improper food or faulty feeding meth- 
ods. Some patients are absolutely indifferent to food; many refuse it 
altogether. In this class a stomach-washing once a day will often be 
followed by a surprising improvement in the appetite. I know of no 
better appetizer for many of these pitiful looking babBs. In not a few 
instances I have been surprised at the large amount of mucus removed 
from the stomach of one of these children in whom there had been no 
vomiting whatever, which teaches us that there may be, in infants, 
stomach disorders of considerable importance without vomiting or, 
in fact, without any other symptom than loss of appetite and 
malnutrition. 

GAVAGE 

Gavage, or forced feeding, is the introduction of nourishment into 
a child's stomach by means of a tube (Fig. 117). The tubes are to 
be obtained at the instrument-makers and are known as "stomach- 
tubes for children," or the physician can make one himself at a small 
cost. All that is required is a soft-rubber catheter, American No. 12, 
a }yi inch glass tube 2 inches long, 2 feet of 3^ inch plain rubber tub- 
ing, and a small glass funnel. An extra opening should be cut in the 
catheter about }^ inch from the original one. This allows a more 
rapid introduction of the nourishment. The opening can very easily be 
made with a small pair of curved scissors. 

The position of the child for gavage may be the same as for stomach- 
washing, or the child may rest on his back (Fig. 118). It is well to 
clear out the stomach with warm water before each feeding. In chil- 



GAVAGE 



791 



dren without teeth the bare index-finger is all that is necessary to keep 
the mouth open. In children with teeth the Denhard gag of the 
O'Dwyer intubation set (p. 640) should be used. 

Gavage, or forced feeding, will be found useful in three types of 
cases: first, as a means of feeding in obstinate vomiting. 

In Obstinate Vomiting. — Several years ago, when the writer was 
resident physician at the New York Infant Asylum, a series of observa- 
tions were made on cases of persistent vomiting which could not be 
controlled by stomach-washing or the ordinary means of treatment. 
It was found that patients who could not retain a teaspoonful of water 
administered by a spoon or a 
bottle would retain from 3^^ 
ounce to one ounce of water 
given through a tube. The 
same child who vomited one 
teaspoonful of milk or other 
food would retain this amount 
and a great deal more when 
the food was given by the 
tube. This discovery led to 
more extended observations. 
Twenty cases of persistent 
vomiting in all were treated 
in this way, of which eight- 
een were relieved. This 
series of observations was 
the first made relating to the 
use of gavage or forced feed- 
ing m persistent vomiting.* 

When used for the obsti- 
nate vomiting cases, it is well 
to use gavage only once every 
four or six hours, with from one- 
third to one-half the quantity 
of food given in health. 

The tube which is to be 
passed into the stomach 
should never be oiled, but 
merely dipped into the solution that is to be used. It is then passed 
in rapidly with the funnel empty and the nourishment is immedi- 
ately poured into the funnel. When the food has passed into the 
stomach, the tube should be compressed and quickly withdrawn, as 
some of the liquid will be retained in the tube if it is withdrawn slowly. 
If this is done without compressing the tube, an escape of food into the 
larynx may take place during the withdrawal of the tube and cause 
choking, coughing, and perhaps vomiting. The food selected should 




Fig. 117. — Stomach-tube. 



* Kerley: "Gavage in Persistent Vomiting in Infants,' 
February, 1891. 



Archives of Pediatrics, 



792 



THE PRACTICE OF PEDIATRICS 



be thin dextrinized gruels, or broths and gruels combined, which have 
answered well in some cases. 

In Severe Illness. — In a severe illness, such as diphtheria, pneumo- 
nia, and the grave intestinal diseases, gavage may save the life of the 
patient. Not infrequently, in such cases, insufficient nourishment is 
taken to support life. Rectal feeding is usually of value only for a day 
or two, as children soon become intolerant of it. In such circum- 
stances, gavage may be employed advantageously for several days at 
a time. In fact, it is the only way by which the child can be properly 
nourished. 




_.:J 



Fig. 118. — Feeding by gavage. 



Predigested cereal foods, completely peptonized milk, and stimu- 
lants well diluted may be given. Usually these patients badly need 
water. If there is no tendency to vomiting, a large quantity of water 
may be given with the nourishment selected, so that they may receive 
as much liquid as they are accustomed to ia health. 

In Malnutrition, Exhaustion, and Narcosis. — Gavage is also most 
useful in cases of extreme malnutrition and exhaustion, or in alcohol or 
opium narcosis. Infants suffering from an extreme degree of malnutri- 



COLON IRRIGATION 793 

tion and exhaustion are often admitted into a hospital; and occasion- 
ally they are seen in private practice. The children are so reduced in 
strength that not enough energy remains for the taking of nourishment. 
In these cases gavage is distinctly a life-saving measure. The food 
should be predigested cereals, peptonized milk, or one of the various 
peptone preparations, given in quantities suitable to the age of the child. 
For a child four months of age, from 2 to 4 ounces of peptonized milk 
may be given every two hours. Before the next feeding it is well to 
introduce a few ounces of water and withdraw it to see if the food has 
been properly digested. By this means of feeding there will be noticed, 
if the vitality is not at too low an ebb at the commencement, a daily 
increase in strength and vigor, which proves that the powers of assimi- 
lation persist after the desire for food or the child's ability to swallow 
it has passed. This proves that we must never regard such a case as 
hopeless so long as the child is breathing. Time and again, after a few 
days' feeding in this way, the child will take the food from the bottle or 
spoon. Breastmilk, if it can be obtained, may be given by gavage as 
successfully as can predigested cow's milk. The malted foods on the 
market have been used temporarily with advantage, for, while deficient 
in nutritive value for the well, they afford sufficient nourishment for 
temporary use in the very ill, and are easy of digestion. 

Illustrative Case. — In. a recent case seen in consultation, the patient, three 
months old, was almost moribund, as the result of extreme malnutrition. The tem- 
perature ranged from 94°F. to 96°F. for several days. No food could be taken. A 
wet-nurse was secured, but the child would not nurse. He was pale, apathetic, and 
too weak to cry. The wet-nurse's milk was drawn from the breast and spoon- 
feeding attempted, but swallowing was impossible. One and one-half ounces of 
breast-milk were fed by gavage, but this proved too strong, and the child promptly 
vomited. The milk was then diluted one-half with weak barley-water. At first 
one ounce was given at a feeding; then this was gradually increased to two ounces, 
all the feedings being retained and digested. In a week the child was able to 
nurse, and made a complete recovery, weighing, when seven months of age, 14 
pounds. At the time gavage was commenced the weight was but 5 pounds. 

COLON IRRIGATION 

Colon irrigation was brought prominently into use several years ago 
as a remedy in the intestinal summer disorders of young children. 
While unquestionably its usefulness in this respect has been overes- 
timated and the irrigation overdone, in selected cases it is of great ser- 
vice. Because a child has summer diarrhea, colitis, or any disorder of 
the intestine, it does not follow that irrigation is indicated or that he 
will be benefited thereby. A child who is having a passage from the 
bowels every half-hour or hour is not, according to my observation, 
a fit subject for irrigation. The colon is kept empty by the active peri- 
stalsis, and the washing will remove nothing more than a few shreds of 
mucus. The cases benefited by irrigation are those in which peristal- 
sis is not particularly active. When a child is running a temperature 
of 102°F. and over, with five or six green mucous passages daily, one 
or two colon irrigations a day will unquestionably be of service in 
removing the offending material from the intestine. 



794 



THE PRACTICE OF PEDIATRICS 



Every year we see a few cases of intestinal infection, particularly 
those of a very acute type, in which there are high fever, intense pros- 
tration, and infrequent bowel action. Occasionally we see a case of 
this sort in which there is no movement whatever without assistance. 
In such cases colon irrigation is of inestimable value, and may be used 
with advantage as often as once in six or eight hours. The washing, 
even if properly conducted, is apt to be strongly objected to by the 

patient and should be com- 
pleted as soon as possible. 
Too frequent irrigation, 
with strong medicated solu- 
tions, may keep up the mu- 
cous discharge indefinitely. 
In a few children the resist- 
ance with straining is so 
marked and so continuous 
that irrigation is impossible. 
These are usually children 
who, on account of the ex- 
cessive peristalsis, do not re- 
quire irrigation. 

The irrigation is con- 
ducted as follows: Normal 
salt solution at 95° F. is 
ordinarily used, and a quart 
usually suffices. If there is 
a great deal of mucus and 
blood, a 1 per cent, tannic 
acid solution is better. 
The irrigation should be 
continued until the solu- 
tion returns clear. The 
temperature of the solution 
may be varied with advan- 
tage, depending upon the 
nature of the case; thus, in 
cases with subnormal tem- 
perature and intense pros- 
tration, cases of the so-called 
"algid" type, the solution 
at 110°F. will act as a decided stimulant. It raises the tempera- 
ture, improves the pulse and the general condition of the patient. In 
cases with high fever — 105°F. or 106°F. — a cold solution answers 
better. I have repeatedly employed a temperature as low as 70°F., 
and have often found that an irrigation with four pints of water at 
70°F. would reduce the body temperature three degrees. 

For irrigation, a soft-rubber catheter. No. 18 American, is best, 
for the reason that its walls are stiff and the tube does not easily bend 




119. — Colon irrigation. 



COLON FLUSHING 795 

Upon itself, as is apt to be the case when an ordinary catheter is used. 
Should this occur, the water may escape an inch or two within the rec- 
tum, and obviously be of no service. When the tube, well lubricated, 
has been introduced for 9 inches, the tip will have passed into the de- 
scending colon, and further introduction will be of no advantage. 
When the end of the tube is in the colon, gentle palpation over the left 
side of the abdomen will enable one readily to locate it. The tube is 
attached to an ordinary fountain-syringe by passing the distal end over 
the smallest rectal tip, which is a part of the outfit of every fountain- 
syringe. The bag should be held not over three feet above the child's 
body. When the water is allowed to run, the buttocks should be 
pressed together, for by so doing we hope to flush the entire large intes- 
tine. If this can be done, the irrigation will be most efiicient. 

In this connection I mention a beneficial effect of irrigation, of 
which we hear but little, viz., the absorption of a portion of the salt 
solution by the intestines. Not a few of the intestinal cases have a 
very limited food capacity. As a result of the vomiting and very 
frequent liquid stools, the body is thoroughly drained of fluids. In 
such cases, after the washing is completed, I endeavor to have the 
child retain as much as possible of the normal salt solution. As an aid 
to this, the child should be placed on his left side with the buttocks 
elevated and the tube introduced well up into the descending colon. 
The buttocks should be pressed together so as to assist in retaining the 
water after it has passed into the bowel. When a half pint or a pint has 
passed in, the tube should quickly be withdrawn and the child kept for 
half an hour in a recumbent position with the buttocks elevated. The 
salt solution will be best retained when it is used warm, at a tempera- 
ture of from 100° to 105°F. 



COLON FLUSHING 

Colon flushing consists in passing into the descending colon a con- 
siderable quantity of normal salt solution or bicarbonate of soda solu- 
tion, 3^^ ounce to 1 pint. 

The measure is used with much benefit in selected cases in which 
but little fluid is taken by the natural channel. I have often been sur- 
prised at the possibilities of the large intestine for absorbing fluids 
when they are urgently needed by the organism. 

Illustrative Cases. — A boy with cyclic vomiting who had retained absolutely 
nothing given by mouth for three days retained one pint at the first colon flushing, 
one-half pint more after six hours, and another half -pint six hours later. The flush- 
ings were begun on the third day of the attack. Although the prostration was 
extreme, the prompt improvement in the general condition of this patient was most 
gratifying. After the first injection the pulse improved, the apathy disappeared, 
the child began to ask questions and showed interest in his surroundings. 

A boy nine years of age, ill with scarlet fever, who could take very little fluid, 
was able to retain eight ounces of a salt solution given at eight-hour intervals for 
three days. 

A child six months of age had retained absolutely nothing in the stomach for 
six days, because of an intussusception. When I saw him on the sixth day the 
respiration was superficial and slow. He was cold and practically pulseless. The 



796 THE PRACTICE OF PEDIATRICS 

second heart-sound could be heard but faintly with the stethoscope. The intus- 
susception, greatly to my surprise, was reduced by water pressure (p. 235). Hot 
salt-water flushings were at once begun; the patient retained twelve ounces, given 
at a temperature of 110°F., and in a few minutes there was a very perceptible im- 
provement. With repeated flushings at six-hour intervals the child continued to 
improve and made a perfect recovery. 

Severe toxic cases of diphtheria and scarlet fever, in which but little 
fluid is taken and in which the toxicity of the blood is extreme, as shown 
by the stupor and delirium, are often much improved by the free use of 
colon flushing, which supplies the water which the child needs, but 
which cannot be given by mouth, or if given may not be retained. 

Method. — I usually order the salt solution given in quantities of 
from one-half pint to a pint, depending upon the age of the child, at 
intervals of from six to eight hours, but never at a lower temperature 
than 100°F. 

The apparatus required is a small rectal tube attached to a foun- 
tain-syringe. 

The flushing is best given with the patient resting on the left side, 
with the buttocks elevated on a pillow, the tube, well oiled, being intro- 
duced at least 9 inches into the bowel. The solution at 105° to 110°F. 
is allowed to pass into the bowel, and the tube is then quickly with- 
drawn. To facilitate the retention of the fluid the patient should 
remain on his side for one-half hour. 

HYPODERMOCLYSIS 

Hypodermoclysis is one of the means employed to introduce drugs 
and fluids into the body other than by the gastro-intestinal route. It 
is used chiefly after hemorrhage, in acidosis, in marasmus and in active 
diarrhea, in cases in which there has been excessive loss of bodily 
fluids. 

In acidosis a 4 per cent, chemically pure, bicarbonate of soda solu- 
tion is employed, alone or with 4 per cent, of dextrose. From 4 to 6 
ounces may be used at one time repeated in ten or twelve hours. In 
marasmus and diarrhea a sterile normal salt solution is used. Netter 
claims to have had signally good results in marasmus in the use of 
sterile sea water. The amount of solution used varies with the age 
of the child or the object in view. From 2 to 4 ounces are usually 
employed. 

In using the bicarbonate of soda after this fashion there is some 
danger of producing necrosis of the tissue at the site of the injection. 
This, according to Rowland, may be obviated by sterilizing the solu- 
tion by heat. The bicarbonate is then changed to the carbonate and 
as the carbonate is very irritating, it must be changed back to the 
bicarbonate. This can be accomplished by passing carbon dioxide 
through the cold solution to which a few drops of phenolphthalein, 
have been added until it becomes colorless. 

That the danger of necrosis in using the chemically pure bicarbon- 
ate of soda in sterile water has been somewhat exaggerated would be 



VACCINE THERAPY 797 

suggested by the observations of my associate, Dr. Mercer Blanchard, 
who used the 4 per cent, solution of the above in 50 infants at the N. Y. 
Nursery and Child's Hospital with a local lesion of but slight irritation 
of very temporary duration. 

The solution is introduced very slowly by gravity, the container 
being placed about 2 feet above the child's body. 

VACCINE THERAPY 

Fundamental Principles. — Vaccine therapy for prevention or cure 
of infection has for its object the production of an active immunity to 
the specific bacteria concerned, while serum therapy produces a passive 
immunity only. 

Immunity, which is resistance or lack of susceptibility to a given 
disease or microorganism, may be natural or acquired. Artificial or 
acquired immunity may be the result of an attack of the disease itself 
or may follow inoculation with living cultures of microorganisms in 
sublethal doses or in an attenuated state with dead cultures, or with 
those products of the growth and metabolism of bacteria known as 
toxins. Immunity so acquired is active or direct, comparatively slow 
in appearance, and of comparatively long, though variable, duration. 
It is brought about by the development in the blood-serum of sub- 
stances antagonistic to the vital activity of the bacteria or to the toxins. 
Such substances are known as antibodies. The serum of an animal 
which has been actively immunized and which is rich in antibodies may 
be inoculated into another animal for the purpose of combating infec- 
tion. The immunity thus produced in the second animal is indirect 
or passive and of comparatively short duration. 

The antibodies are of several kinds : agglutinins, opsonins, bacteri- 
cidins and lysins. They are formed by the tissue-cells under the stimu- 
lus of the infecting bacteria, at first locally, then generally, and are 
present in the serum and to a lesser extent in the other body fluids. 
They manifest themselves in certain definite ways, demonstrable and 
measurable by laboratory methods: agglutination reaction, opsonic 
index, bactericidal tests, and the complement deviation test. Clinic- 
ally, their increase is accompanied by amelioration of the symptoms of 
infection. The aim of both vaccine and serum therapy, then, is to aid the 
production of antibodies in order to effect a destruction of the invading bac- 
teria and the neutralization of their toxins. Metchnikoff claimed that 
the destruction of microorganisms is brought about by their ingestion 
by phagocytes, especially polymorphonuclear leukocytes. Denys and 
Leclef proved that there is a substance in the blood-serum which pre- 
pares the bacteria for phagocytosis. This sensitizing substance was 
named "opsonin" by Wright and Douglas, who elaborated methods for 
its study in the laboratory and for its practical application to the treat- 
ment of infections by means of vaccines made of suspensions of dead 
bacteria. 

It has been found in general that the opsonins are below normal at 



798 THE PRACTICE OF PEDIATRICS 

the onset of an infection and during the height of the acute stage, and 
that, as improvement occurs, the amount of opsonin in the blood-serum 
increases. The administration of dead cultures of the bacteria causing, 
the infection stimulates the production of opsonins. 

The suspension of bacteria is made in normal salt solution from an 
agar-culture not over twenty-four hours old. It should not be too 
thick, and should be free from clumps, which may be recovered by shak- 
ing or by manipulating with a capillary pipet. 

Capillary pipets of the same caliber having been selected, equal 
quantities of the patient's serum, leukocytes, and bacteria are drawn up 
and thoroughly mixed in one, while normal serum, leukocytes, and bac- 
teria are drawn into another. A control, using normal salt solution 
instead of serum, should also be made. The pipets are sealed below 
and incubated for fifteen minutes at 37*^C. The mixture is then ex- 
pelled on a glass slide, thoroughly mixed again, and spread on clean 
slides. After fixing in methyl-alcohol and staining in methylene-blue 
(Manson stain is excellent for the purpose) , the slides are placed under 
the microscope and the number of bacteria contained within 50 leuko- 
cytes is counted. This gives the phagocytic index. The quotient of 
the patient's and the normal phagocytic indices equals the opsonic index 
of the patient. More satisfactory results have recently been obtained 
by making the tests w^th diluted serum, according to Neufeld. The 
opsonins in the normal blood-serum used for control are found to dis- 
appear in a lower dilution than do the immune opsonins in the blood of 
the patient who has been immunized by the disease or by the adminis- 
tration of vaccines. Detections from 1 : 10,000 may be made. 

Preparation of Vaccine. — A vaccine is made by suspending agar- 
cultures less than twenty-four hours old in normal salt solution. In 
order to estimate the dose even approximately, the bacterial suspen- 
sion is standardized by counting the bacteria in relation to red blood 
cells. The method is as follows : Equal quantities of bacterial suspen- 
sion and of blood from a normal person are drawn into a capillary pipet, 
mixed, and thinly spread on a slide. The red cells and the bacteria 
are then counted ia a number of fields. Since the normal blood con- 
tains 5,000,000 red cells to the cubic millimeter, the number of bacteria 
in proportion to the red cells can be estimated per cubic millimeter, 
and the actual count per cubic centimeter readily calculated. The 
tube containing the bacterial suspension is sealed and heated for one 
hour at 58° C. Control cultures are then made to test the sterility of 
the undiluted suspension. This having been properly accomplished, 
the vaccine is diluted in bottles or ampules with sterile normal salt 
solution, according to the dose desired per cubic centimeter, and prop- 
erly sealed. Thus, if the actual count showed that 5,000,000,000 
bacteria were present in a cubic centimeter, diluting the vaccine 50 
times by adding one cubic centimeter of undiluted vaccine to 49 c.c. 
of sterile salt solution would make a vaccine containing 100,000,000 
bacteria in one cubic centimeter. Injections of one cubic centimeter 



VACCINE THERAPY 799 

or less are made into the shoulder, back, or thigh under strictest 
aseptic precautions. 

Staphylococcus. — It is in staphylococcus infections that the vaccine 
treatment has given the best results. While it is always wise to use a 
vaccine prepared from the patient's own strain of staphylococcus, it 
is not absolutely essential that this be done. Any stock vaccine which 
has given good results in a similar case may be used, provided that it 
has been proved by a culture made from the pus of the patient's lesion 
that staphylococci are the infecting agents. It is essential also to know 
whether the Staphylococcus aureus or albus be present, in order that 
the appropriate vaccine may be employed. The dose in infants under 
two years should vary from 50,000,000 to 100,000,000 of dead cocci. 
The inoculations are repeated on the second to the seventh day if 
necessary. As a matter of fact, the test for the opsonic index has been 
found to he too uncertain to make it practical and worth while to follow 
systematically , the clinical symptoms being sufficient indication of the 
value of the vaccines. Too rapid or too large dosage must be avoided, 
because there is danger of exhausting the responding power of the hu- 
man organism by overstimulation . The temperature should be taken 
before the vaccine is injected, and every three hours during the follow- 
ing twenty-four. 

Furunculosis in young infants has proved readily amenable to treat- 
ment by staphylococcus vaccines. Improvement is shown by a much 
more rapid healing than usual of the furuncles already incised, and by 
the non-appearance of new ones. After the second inoculation im- 
provement is the rule. The amount of pus is lessened and fewer 
dressings are required than in cases otherwise treated. No bad effects 
from the injections have been noted. 

In treating otitis media of staphylococcus origin, vaccines are re- 
ported, evidently by enthusiasts, as having proved of value, also in 
treating suppuration in the antrum, styes, osteomyelitis, and empyema. 
In rare and favorable cases of the latter disease it is claimed that op- 
eration may be obviated by the vaccine injections. After operation 
the vaccine may prove of real service in aiding the more rapid disap- 
pearance of pus from the pleural cavity and in hastening the healing 
of the wound. 

Any local suppuration due to staphylococci is rapidly benefited by 
vaccine administration. In general septicemia the results have been 
encouraging (Wright). Fifty million dead bacilli are to be given at 
the first injection; this is followed in five days by 100,000,000 and again 
in five days by 100,000,000. The subsequent administration is depen- 
dent upon the requirements of the case. 

Streptococcus. — In all cases of streptococcus inflammations the 
results of vaccine therapy have been far less brilliant than in staphy- 
lococcus cases, but still encouraging enough to warrant their further 
use. It seems to be essential, also, far more than in the staphylococcus 
injections, that the vaccine be prepared from the strain of streptococcus 
isolated from the patient. The dose is about 2,000,000 to 3,500,000 



800 THE PRACTICE OF PEDIATRICS 

in babies under one year of age, 5,000,000 to 7,000,000 between one 
and two years, 10,000,000 to 30,000,000 in older children. 

Erysipelas. — In erysipelas Shorer found that the course of the dis- 
ease is apparently shortened by the inoculation of dead streptococci, 
but that neither migration nor recurrence seem to be prevented. 

Scarlet Fever. — In scarlet fever the opsonic index to streptococci 
has been studied by Tunnicliff, who found that it is below the normal 
at the onset of the disease, but rises when the acute symptoms subside. 
As local streptococcus complications appear the index falls once more. 
Favorable results following the injections of dead streptococci in cases 
of scarlet fever have not been reported. On the other hand, this 
treatment of streptococcus inflammations — like subacute or chronic 
joint affections — has given encouraging results. 

Typhoid Bacillus. — Inoculations of dead typhoid bacilli as a pro- 
phylactic measure against typhoid fever have been extensively em- 
ployed in the British, German, United States, and Japanese armies. 
The most recent statistics (Russell) show that the incidence of disease 
is 6 to 15 times as high among the non-inoculated as among the inocu- 
lated soldiers. Not only are the numbers of cases far less numerous 
among those who have been vaccinated, but the clinical course is much 
less severe and much shorter, while complications are fewer. In view 
of these results prophylactic inoculation of children as well as of adults 
is to be recommended during epidemics of typhoid fever or before en- 
tering a typhoid district. Immunization is accomplished in three 
vaccinations, the dose of which, in children, may be 100,000,000 to 
500,000,000 dead bacilU. 

By lowering the incidence of typhoid fever cases antityphoid vac- 
cination prevents the development of carriers of typhoid bacilli, and 
thus is fully justified. The development of carriers by the inoculation 
has been reported, but it is rare. 

Gonococcus. — In vulvovaginitis due to the gonococcus in infants 
under one year of age, the injections of dead gonococci have had no 
effect in shortening the course of the disease, in lessening the amount of 
discharge, nor in causing the cocci to disappear from the vagina. In 
older children Hamilton and Cooke found that the effect of the dead 
gonococcus injections is more marked in chronic than in acute cases, 
the disease being very decidedly shortened in its course. The later 
stages of the acute cases were also shortened, while no result was noted 
in the first weeks of the attack. Hamilton and Cooke observed no 
advantage from the use of a vaccine made from the patient's own 
organism. The initial dose of 5,000,000 was gradually increased to 
40,000,000 or 50,000,000, according to the needs of the case. Injec- 
tions at eight- or nine-day intervals proved best. (For personal obser- 
vations see p. 469.) 

Meningococcus. — In cerebrospinal meningitis due to the meningo- 
coccus of Weichselbaum vaccine therapy has been tried, but it has be- 
come superfluous in view of the brilliant results obtained by means of 
the anti-meningococcus serum of Flexner and Jobling. 



VACCINE THERAPY 801 

Bacillus Coli Communis. — Inoculations of dead colon bacilli in 
doses of 10,000,000 to 50,000,000 are reported to have given excellent 
results in cases of cystitis and pyelitis due to that microorganism. The 
symptoms are said to subside rapidly, and the bacilli to disappear from 
the uriae ia a comparatively short time. 

Tubercle Bacillus. — ^Local tuberculous lesions have been treated by 
injections of tuberculin in very small doses with good effect. This is 
true of chronic local tuberculosis without constitutional symptoms, 
especially iu bone, joint, gland, skin, and eye affections. In pulmonary 
phthisis of a chronic type, running a nearly apyretic course, tuberculin 
is also of value. In all acute tuberculous lesions with marked fever 
and general symptoms tuberculin therapy has proved useless, and it 
may be attended by grave danger. The dose of crude tuberculin,* 
administered for purposes of immunization in a chronic tuberculous 
lesion, should be very small, 3^^000 milligram, gradually increased to 
3^000) Ho 00) 01" more. The inoculations should be repeated not oftener 
than once in ten days, at first, and the temperature carefully measured 
every two hours. If a rise occurs, the dose has been too large, and must 
be reduced at the next injection. In selected cases of bone and joint 
disease and also in adenitis,' good results have followed six or eight 
months of continued treatment, the dose being gradually increased 
in amount and the intervals shortened to three days. 

* Koch's old tuberculin, prepared by the New York City Board of Health. 
51 



XXI* GYMNASTIC THERAPEUTICS 

The section on Gymnastic Therapeutics is included in order to 
call the attention of general practitioners to the value of such work 
and to assist them in applying necessary treatment. Exercises are 
most often used therapeutically for children in the treatment of the 
following conditions : Flattened or narrowed thorax, kyphosis, scohosis, 
flat-foot, congenital ataxias, and acute anterior poliomyelitis; also in 
cases of habitual constipation, malnutrition, etc. 

The following pages contain a description of the methods which 
have been carried out most successfully with my patients by Dr. Hugh 
Currie Thompson, of New York, to whose patience and skill I am in- 
debted for the recovery of many cases, some of which had resisted 
other methods of treatment. 

The family physician has an opportimity of seeing these conditions 
at a much earlier stage than has the specialist, and at a time when they 
may be more easily corrected than in later life. When discovered, such 
conditions should never be neglected with the idea that in time the child 
will outgrow them. Such a belief is often fallacious, for unless properly 
treated, they are apt to become permanent. The necessity for the cor- 
rection of physical defects in children is readily appreciated by parents. 
Certain principles or rules are involved in every form of practice. The 
following principles are generally applicable in gymnastic therapeutics. 

RULES 

I. Examination. — ^As far as possible, obtain a complete history of 
the case. Make both a general and a detailed physical examination; 
under the latter, note the musculature, condition of the skin, posture, 
any deviation of the spine, position of thorax and scapulae, side hues of 
body, compare length of limbs, note the condition of the feet. It is 
often advantageous to take the height and weight and certain measure- 
ments, such as girth of neck, chest, and waist, and depth of chest and 
abdomen. In cases where the nervous system is especially involved, 
apply the tests usually made in such cases. 

n. Conditions Under Which Exercise Should be Taken. — Temper- 
ature of Exercise-room. — The temperature of the room should be from 
70° to 75° F., depending upon whether or not the patient is dressed. 
There should be no draft upon the patient. Therapeutic gymnastics 
involves fewer groups of muscles than ordinary gymnastic work and 
the execution is slower. The general circulation and respiration are 
not stimulated as much, and, therefore, the heat-production is less. 

Clothing. — In the beginning, the parts of the body involved in the 
exercises should be devoid of clothing. A single thickness of clothing 

803 



804 THE PRACTICE OF PEDIATRICS 

may mislead as to the corrective effect obtained. At frequent intervals, 
at least once a week, the child should be uncovered for the purpose of 
observation during exercises. It is sometimes desirable to have the cloth- 
ing removed during each treatment. At all times a child's clothing 
should be simple and hygienic, permitting unhampered movements. 

Double Mirrors, Etc. — The use of double mirrors and a stringed 
screen are sometimes desirable so that the child may see when he has 
a correct position. 

III. Frequency and Duration of Treatments. — Treatment should 
be given either for a half -hour or an hour, three times a week, or a half- 
hour or an hour daily (Sundays and holidays excepted), the arrangement 
being dependent upon the needs of the case and the physical condition 
of the patient. The above is not too often if the following points are 
considered : 

(a) The length of time during which the condition has been developing. 

{h) The number of waking hours intervening between treatments 
when faulty postures are apt to be maintained. 

(c) That progress should be made as rapidly as possible, so that 
the changed .structure may be the basis for the period of growth. 

Many times this rule must be modified, owing to the physician's 
lack of time and the expense to the patient's family. Instead of an hour's 
supervision daily, it may mean supervision by the physician only once 
every two weeks, supplemented by careful home supervision fifteen 
minutes daily. This should be the minimum of attention given to any 
case. 

IV. Prescription of Exercises. — Forms of Exercise. — No certain sys- 
tem of exercises need be followed as long as the exercises used have 
an anatomic and physiologic basis. Both active and passive move- 
ments are used with and without resistance. Exercises with resistance 
given by the physician are used much in corrective work, for in this 
form of exercise the physician can easily judge as to the amount of ex- 
ertion, and increase or decrease it at T\dll, and the physician should re- 
member that in most cases the stretching of the contracted muscles is 
quite as important as the strengthening of the weak and overstretched 
muscles. In cases of paralysis, injury, kyphosis, and scoliosis, where 
the weak muscles need treatment to restore their normal strength, the 
antagonistic muscles which are contracted and shortened should be 
stretched at every treatment (even though tenotomy has been per- 
formed) until the weak groups have regained their normal tone. 

Accuracy of Execution. — Accuracy of execution of each and every 
exercise given in the prescription is essential. A possible exception 
to this might occur in the treatment of such cases as malnutrition or 
constipation, where exercise per se is the essential thing, but even in 
these cases conditions may be such that very careful work is necessary. 
A prescription of exercise in itself means little. The manner in which 
it is executed may actually aggravate the condition, as the wrong muscles 
may be made stronger by a faulty manner of execution. In writing 
out a prescription of exercise the physician should be guided by the 



RULES 805 

patient's capability for fairly accurate execution of each exercise. This 
cannot be gaged by the physical examination alone, but the examination 
must be supplemented by having the patient try the exercise for one or 
more days. Unless he can approximate the proper execution without 
assuming faulty positions or postures and without causing too much 
nerve and muscle fatigue, simpler exercises should be used. As the pa- 
tient improves or becomes stronger, more difficult exercises should be 
given. In advancing, the rule regarding accuracy should be observed. 

Exercises have several details which need to be watched in order 
to secure accurate execution. At first do not confuse the child by re- 
quiring absolute accuracy as to every detail; rather select one or two 
of the more important ones and insist upon the most rigid observance 
of these. As the child grasps and retains these ideas and is able to carry 
them out, require more, until all are mastered. 

Concentration. — Frequent repetition of the exercises is necessary to 
obtain desired results. In repeating an exercise many times, a child easily 
forms the habit of executing it with but little effort, which will soon 
result in inattention and carelessness. When this occurs, bring about 
an increase of exertion on his part by insisting that every detail be 
mastered, or change to more difficult exercises. 

Overwork. — If a child is fatigued at the end of an hour's rest follow- 
ing the treatment, he has been overworked, and the exercises should be 
made less difficult. A certain amount of muscle soreness must be 
expected during the first few days of work. 

The patient may be weak and anemic. This should be borne in 
mind when the amount of exercise is increased. There should be less 
school work or play to insure sufficient rest and recuperation after the 
treatment. If that is not possible, the amount of exercise should be 
increased very gradually. Otherwise, overfatigue may result from the 
carrying-out of exercise excellent in other respects. 

Rest. — In many cases the child should rest in a recumbent posture 
for half an hour after the treatment, and in nervous cases the treatment 
should be preceded by a half-hour's rest. 

General Health. — Attention should be given to everything that will 
build up the general health of the patient, such as bathing, sleep, fresh 
air, general exercise, diet, and dress. Suitable furniture (chairs, tables, 
or desks, etc.) should also be considered. Attention to these things 
will sometimes shorten the time of treatment by ehminating causative 
factors. 

Temporary Discontinuance or Modification of Exercises. — When 
the child feels indisposed, or there is an acute illness of an apparently 
simple character, the temperature should be taken. If fever is present, 
exercise should be omitted until the nature and seriousness of the illness 
are known . If there is no fever, the amount of exercise should be modi- 
fied by providing one-half or one-third of the amount which otherwise 
would have been given, or the same amount of time with movements 
which require less exertion. 

When a child having a lithemic diathesis, with predisposition to ca- 



806 THE PRACTICE OF PEDIATRICS 

tarrhal conditions of the throat and bronchial tubes, is suffering from an 
acute cold, the exercises should be temporarily discontinued, or the 
amount of exercise reduced to one-third. If this precaution is not ob- 
served, a cardiac strain may result, such as sometimes follows play or 
exercise in one who has had acute rheumatism. 

V. Adaptation of Exercise to Practical Ends. — ^Adapt corrective 
positions to all practical ends: walking, sitting, working, or playing. 

VI. Cooperation. — Endeavor to secure the cooperation of mem- 
bers of the household, teachers, or servants between exercise periods 
in order that the progress of the child may be as rapid as possible. A 
child is not at first capable of adapting the work to practical ends with- 
out careful oversight by elders. 

There are two objects in treatment: One which should always be 
obtained, that of improvement; and the other, complete and per- 
manent correction, which should be the aim until an insurmountable ob- 
stacle is reached. To gain these are required continuous and conscien- 
tious work, and the cooperation of those in charge of the child and of 
the child himself. As a rule, these objects cannot be obtained in a short 
period of time. 

After the treatment has been completed the child should be brought 
for examination every three months. 

POSTURE AND BREATHING 

Posture and breathing will first be considered, as they hold an im- 
portant place in the correction of the conditions about to be considered. 
A good postmre should be maintained during all exercises. Between 
treatments the child should maintain as good posture as his condition 
will permit. Telling him to do this is not sufficient: he should be 
given exercises which will strengthen the weakened and overstretched 
muscles and stretch the contracted ones, and thus enable him to assume 
an improved posture. The work for correcting posture should be taken 
up gradually. Have a child hold a good posture for short periods of 
time, beginning with one minute and working up to fifteen minutes. 
The child should be taught to assume and maintain a good posture dur- 
ing the entire day, no matter what he is doing, whether at work or play. 
In the standing posture the weight of the body should be brought for- 
ward until it rests over the balls of the feet or over a point midway be- 
tween the toes and the heels. In sitting, the weight of the body should 
be carried over the posterior third of the thighs. 

For general posture, my rule consists of the following steps: Heels 
together, or approximately so; knees well stretched; chest raised high; 
head erect with chin in (stretch up entire body as high as possible) ; 
poise weight forward over balls of feet ; bring shoulders back and down. 
The feet should be turned outward slightly or kept straight. (See Fig. 
120.) 

In the above rule do not relax any previous step as a new one is taken. 
In sitting, insist that the hips be pushed well back in order that the child 



POSTURE AND BREATHING 



807 



may not slide forward so as to bring the weight of the body over the 
lower spine. 

From the beginning, an attempt should be made to improve the 
posture. Take the essential details for the child to follow and in- 
crease the requirements as fast as practicable. These individual details 
have been tersely expressed in different ways, and one expression may 
convey the idea of the detail more clearly to one patient and another 
expression to another. For instance: ''Chest 
Up!" may mean that you wish the child, if he 
has relaxed, to take the best possible posture of 
the thorax. In taking a good position of the 
thorax, there should be no raising of the 
shoulders, no conscious taking in or holding of 
the breath, and the trunk should not be inclined 
backward, nor the pelvis or abdomen permitted 
to project forward. 

General Considerations. — 1. When children 
use bicycles, velocipedes, mail wagons, etc., 
where they propel themselves by pedaling, they 
should not ride with head and shoulders forward 
and chest contracted to gain advantage and 
leverage, but should have the body inclined 
forward from the hips, back straight, and chest 
expanded. 

2. Improper and insufficient diet, poor as- 
similation, lack of fresh air, and disturbed sleep 
cause a loss of general tone, which tends to make 
a child relax and assume bad postures. All 
these matters should receive attention. (See 
Tardy Malnutrition, p. 100.) 

3. Clothing should be examined to see that 
it causes no pressure or tension. All garments 
should be loose and simple. The underclothing 
should be elastic and light in weight. The stock- 
ings should fit the feet and should be supported 
by soft elastics extending from V-shaped pieces 
at the side of the waist, which catch the stock- 
ings on the outside of the legs. The shoes should 
have flexible soles, a fairly straight line on the 
inside, a low broad heel, and should be broad 
enough to permit the toes to spread. So much 
depends upon the condition of the feet, both 

in standing and walking, that they should receive as careful daily 
attention as the hands. Hats should first be for protection. They 
should be light in weight and should come far enough forward to pro- 
tect the eyes from the sun, and should never be worn far enough back 
to make the child tilt his head to balance the weight, or to make him 
bend it forward to protect his eyes from the sun. Outside wraps should 




Fig. 120. — General pos- 
ture. 



808 



THE PRACTICE OF PEDIATRICS 



be sufficiently light in weight and flexible enough to permit free move- 
ment in walking or running. 

4. Sleep. — A child should not form the habit of sleeping always on 
one side with the knees drawn up to the chest, but change from side to 
side. If the posture is very poor, he should for some time sleep on the 
back with limbs extended, and without a pillow. The mattress should 
be thin and firm, and the child's covering light in weight, and only a 
small pillow used. 

5. Furniture. — The furniture a child uses, especially his chairs, tables, 
or desks, should be adapted to his age and height. Furniture not prop- 
erly adapted to children is one of the main causes of bad posture. Chairs 
should have the height of seat correspond to the length of the lower leg. 




Fig. 121. — Adjustable table, Dr. Mosher's chairs, board, ladder, and blocks for ataxic 



exercises. 



The child's feet should rest comfortably upon the floor, and there should 
be no pressure under the knee. The depth of the seat should be no 
more than the length of the thigh. If it is greater, the child tends to 
slide forward and assume a bad posture with the weight of the trunk 
over the lower spine. The back of a chair should not have upright 
spindles, but cross-pieces, or, at least, one cross-piece sufficiently high 
above the seat to allow the fleshy part of the hips to project underneath 
it in order to bring back the tuberosities of the ischia far enough to sup- 
port the weight of the trunk in a good position.' The lower cross-bar, 
preferably adjustable, should support the back at the junction of the 
dorsal and lumbar vertebrae. In addition there should be another cross- 
bar to support the upper back. 

Dr. Mosher's kindergarten chair, sold by The Milton Bradley Com- 



POSTURE AND BREATHING 809 

pany, 11 East 16th Street, New York city, is the best chair for children 
that has come to my attention. It is constructed in three sizes, with 
seats ten, twelve, or fourteen inches in height, but there is no lower cross- 
bar for the support of the back. If the seat of a chair is hollowed out, 
there should be no raised border at the back, as it would prevent the 
hips from being pushed well back. If well-constructed chairs cannot be 
obtained, ordinary chairs may be modified for use in the nursery or for 
older children, by selecting those having a cross-bar several inches from 
the seat and sawing the legs off. If the seat proves too deep, a pillow 
may be placed between the child's back and the back of the chair, but 
should not extend below the waist-hne. It may be held in place by tapes. 

6. Heredity. — Parents often attribute a bad posture ^vith flat chests 
or other physical deformities to heredity, saying that a child "takes 
after" one parent or the other. Heredity is usually only a slight factor, 
i. e., the child may inherit a frame or general constitution or certain 
mental and physical characteristics resembling those of a parent, but 
the faulty posture, flat chest, etc., are in most, if not all, cases acquired. 
A well-nourished infant has a straight back. In a well child, one seldom 
sees a flat chest before the age of three years. 

7. In very young children the deformity is often induced by the 
position assumed in play. For instance, the sitting position on floor 
or bed, with legs extended and spine bent forward, which most young 
children assume in playing, keeps the chest in a bad position for long 
periods of time day after day. This is especially true if, for any reason, 
the back muscles are not as strong as usual and cannot easily maintain 
the weight of the trunk in an erect position. For children who are kept 
in bed when not seriously ill, a folded blanket or air-cushion may be 
used as a seat, and a bed-table or tray for playthings and meals. A sup- 
port may be used for the back if needed. 

Fig. 121 shows Dr. Mosher's chair and an adjustable table, which 
may be made for use in the nursery. The top of the table, 23^ by 4 
feet (or 3 by 5), is made of well-seasoned boards, 3^ inch in thickness. 
These boards are held together by quarter-inch pegs and holes, as are 
the leaves of an extension dining-table. Two sets of light-weight wooden 
horses (legs ^ by 2 inches and cross-pieces 1 by 23^2 inches) are used 
for supports: one set, for use when the child is seated, 14 to 18 inches in 
height; the other, for use when standing, 24 to 30 inches in height. If 
desired, the whole may be painted white or stained and varnished. For 
reading there should be a book-support for the child's books, so that he 
may keep his head erect. 

8. School Hygiene. — Physicians as well as parents should interest 
themselves in school conditions, as often it is in school that the child 
contracts bad postures, because of the long hours of confinement, un- 
suitable desks and seats, and frequently by a lack of proper ventilation. 

Exercises. — The following exercises may be used for correcting bad 
posture : 

1. The child stands mth toes from 2 to 4 inches from a flat, perpen- 
dicular surface, as a closed door. Let him assume a good standing 



810 



THE PRACTICE OF PEDIATRICS 



position; sway the body forward from the heels (heels kept on floor) 
until the chest touches the door; but neither the abdomen nor head 
should touch it. (See Fig. 122.) 

2. Raise arms sideways to shoulder height; lift heels; stretch up 
with head and chest, in with chin, and out with arms. 

3. The child lies on his back on a fairly hard, flat surface. Place 



K- 





Fig. 122. — Posture exercise. 



Chest raising against a flat, perpendicular 
surface. 



your hands under his head, raising it an inch or two. He then, re- 
clining as before, arches his body from head to heels. (See Fig. 123.) 
The knees should be kept straight. In the beginning, as in figure, he 
may aid himself with his hands in arching body. Later the arms should 
be folded lightly on the chest. 



POSTURE AND BREATHING 



811 



4. The child standing, should raise arms sideways, turn palms up 
at shoulder height, and continue to raise them until the hands are mid- 
way between horizontal and vertical; sway body forward; stretch up 
with chest and head, in with chin, and out and up with finger-tips. 

5. Clasp hands, back of head. Raise chest well and press head 
backward, chin in, resisting with hands. Keep elbows well back. 

Walking Movements. — Have patient walk on balls of feet, mth arms 
extended sideways, shoulder high, maintaining a good posture. When 
capable of doing this satisfactorily, repeat with arms raised over head; 
arms should be well stretched, fingers straight, palms facing and sepa- 
rated by the breadth of the shoulders. 

Shot-hag Exercises. — A flat circular bag, 5 or 6 inches in diameter. 
The bag should hold from J^ to 2 pounds of shot, according to the 
strength of the child. With the child's back straight and chest expanded, 
head erect and chin close to neck, have him balance the shot-bag on 




Fig. 123. — Posture exercise. Arching body. 



top of his head: balance while sitting or standing from one minute up to 
thirty minutes ; balance while rising from a sitting to a standing position 
from 5 to 50 times; balance while walking forward and backward across 
the room from 5 to 20 times; balance while walking on the toes across 
the room forward and backward from 5 to 20 times; balance the bag 
on the head while being read to; balance while taking the out-of-door 
walk for varying distances from 100 feet to 3^ mile; balance while run- 
ning in an easy manner. 

Static Exercises. — Exercises of Position. — Simply telling a child to 
think, himself, to keep a good posture, presents the matter to him only 
in the abstract, and involves a mental strain. He must be given certain 



812 THE PRACTICE OF PEDIATRICS 

things to do. The static exercise reduces the instruction to the concrete, 
and there is usually some responsive cooperation from the child. The 
use of the static exercises makes a good posture possible for the child, 
and they serve as an introduction to a habit of improved posture. The 
static exercises should be used in connection with the developing exer- 
cises, but only one set should be taken up at one time, to be continued 
from one to three weeks, and then another set taken up as conditions 
seem to require. 

Illustrative Case. — The brother of a little patient was a persistent mouth-breather. 
Some months previous both tonsils and adenoids had been removed. The habit of 
mouth-breathing persisted, although its causes had been eliminated. I suggested 
that the mouth be kept closed, and that breathing through the nostrils be made an 
exercise, beginning with a minute on the first day and increasing a minute or two 
each day until the child could continue to breathe with closed lips for an hour. He 
was read to while doing this. He was urged to think of holding the hps closed at 
other times. He soon overcame the habit of mouth-breathing. This illustra- 
tion shows that habit must be reckoned with — the removal of the cause does not alone 
suffice. 

The following static exercises may be used with advantage to aid 
in the correction of bad posture : 

Lying on Couch or Bed in Good Position. — Have patient take such 
position from one to ten times daily in order that he may learn to assume 
a good position whenever he takes a lying posture. The last time he 
should remain in a correct lying posture from five to twenty minutes. 

Correct Sitting. — Have patient assume a correct sitting posture, 
beginning with a minute, once, twice, or three times in each school ses- 
sion, at each meal, during each study or reading period at home. Grad- 
ually increase the time until the child is holding a good sitting position 
from five to fifteen minutes during the above suggested period. 

Correct Standing. — (a) Have patient rise from correct sitting to a 
correct standing position from four to ten times, (b) Have child when 
spoken to take good standing posture before replying. Often a child 
assumes his worst standing posture when spoken to, his mind being in- 
tent upon what is said to him, and he relapses into the original poor 
posture, (c) Have child hold good posture for from two to five minutes 
while conversation is carried on. 

Similar ideas may be carried out while walking, running, skating, 
dancing, etc. 

BREATHING 

The primary object of breathing is to aerate the blood by carrying 
oxygen to it by the air that enters the lungs; secondarily, through the 
practice of deep breathing, the accessory muscles of respiration are de- 
veloped, the breadth and depth of chest and the lung capacity are in- 
creased. In deep respiration the amount of air taken in is several times 
that inhaled in ordinary respiration. The amount inhaled in ''tidal" 
respiration by an adult is 30 cubic inches, while that which can be taken 
in by forced inspiration is from 150 to 300 cubic inches. Daily practice 
of deep breathing in the open air helps to increase the resistance of the 
• lungs to diseases to which they are liable. 



BREATHING 813 

A mistake is sometimes made in overdeveloping the chest muscles, 
so that the chest becomes to a certain extent ''muscle-bound," and the 
expansion is lessened, instead of increased. There is little danger of 
this when the development comes from taking deep inspirations rather 
than by muscular activity alone. While a development of the chest 
muscles is desirable, they should not be developed at the expense of the 
normal expansion of the "respiratory chest." The aim should be to 
improve the mobility of the chest and the lung capacity as well as to 
strengthen the muscles. 

Two kinds of breathing are usually spoken of : thoracic and abdominal. 
Breathing should be considered as a whole, unless one form is especially 
lacking, as, for instance, where a child has a very flat chest in which 
diaphragmatic or abdominal breathing greatly predominates over the 
thoracic, and there is httle mobility in the upper part of the chest. If 
the abdominal breathing needs to be developed, have the child stand in 
a good posture, with hands placed Hghtly over the lower ribs, with tips 
of the fingers two or three inches from the median line, and take long, 
deep breaths until he secures a good movement of the lower ribs. The 
hands are placed over the ribs only for the purpose of feeling the move- 
ment. 

All breathing exercises should be taken with the body in a good po- 
sition and may be done while standing, lying, sitting, or slowly walking. 
Ordinarily they are taken in a standing position. If the muscles are 
weak or if it is difficult to stand in a good position, the exercises may be 
taken in a sitting or reclining position. When the breathing exercise 
is taken reclining, a couch or a board resting on two chairs may be used 
in preference to a bed or the floor. A small hard pillow or a folded bath- 
towel may be placed under the shoulders and upper back, but should 
not extend under the head. Such a pad is used with advantage in cases 
of kyphosis and lordosis. 

It is better to take the deep breathing exercises in the open air, on 
the highest elevation in a nearby park, or during the daily outing, or 
even while walking to and from school or while driving. However, one 
must adapt himself to existing conditions, and at home the exercises 
may be taken on a piazza or balcony, or even indoors, with wide-open 
windows, but the air should be as free from dust as possible. If the 
windows are open in winter, the child should wear extra wraps or 
clothing. 

A breathing exercise should be preceded by a number of strong, 
sharp exhalations through the mouth in order to empty the lungs as 
thoroughly as possible of residual air, so that the deep inspirations may 
fill the lungs with fresh, pure air. 

The clothing should always be loose, with no constrictions at neck 
or waist. 

Holding the breath at the end of full inspirations may be done to 
advantage, if it is not held longer than five seconds. Retaining the air 
after full inspiration causes it to become warmer. As it becomes warmer 
it expands and penetrates the better into the alveoli. Retaining the 



814 



THE PRACTICE OF PEDIATRICS 



air from one-half to one minute or longer is not wise. Becoming warmer, 
it continues to expand and may overdistend the alveolar walls. Pro- 
longed holding of. the breath has also a deleterious effect upon the 
heart. 

If, when the child begins to take deep breathing exercises, he feels 
dizzy, he should not at first fill the lungs to their greatest capacity or 
hold the breath, and each deep inspiration should be followed by several 
ordinary ones. After a few days the dizziness usually ceases. 

In all cases deep breathing and respiratory exercises should be given. 





J 



Fig. 124. — Breathing exercise. Inhale as arms are raised, sideways, upward, to 

vertical. 



They are of special value in malnutrition, constipation, flat chest, and 
scohosis. 

Breathing Exercises. — Take a good standing posture. 

1. Inhale deeply and exhale slowly. 

2. Place hands lightly on lower chest. Inhale deeply; exhale. 

3. Place hands hghtly on upper chest, elbows well back and down. 
Inhale deeply; exhale. 

4. Inhale as arms are raised sidew^ays to shoulder height. Exhale 
as arms are lowered. 

5. Inhale deeply as arms are raised forward and upward, to a vertical 



FLAT CHEST 815 

position. (From the beginning have elbows, wrists, and fingers straight, 
palms facing each other and separated by the breadth of the shoulders.) 
Exhale as arms are lowered sideways. 

6: Inhale as arms are raised sideways to vertical. (Elbows, wrists, 
and fingers straight — ^turn palms up when arms are shoulder high.) As 
vertical is reached, bend head sHghtly backward, stretch up and continue 
inhaling, while you slowly count three. Raise head; exhale as you 
lower arms sideways. (See Fig. 124.) 

In the illustration the wrists are strongly flexed and the palms are 
not turned in, raising to vertical. The action is stronger. Either po- 
sition of the hands may be used. 

7. Arms at sides, elbows, wrists, and fingers extended. In one quick, 
continuous movement raise arms forward and flex forearms upon the 
chest, palms down, elbows drawn well back. At the same time a step 
forward is taken — the weight of the body is supported over the forward 
foot, the ball of the other foot resting on the floor. With the above move- 
ment inhale deeply. Exhale as the arms are lowered to side. 

In Nos. 4, 5, 6, and 7, above, put the emphasis on the upward move- 
ment. In lowering the arms, keep chest high and arms well stretched, 
but make the movement an easy one. 

If the heart is weak, in the above exercises the arms should not be 
raised above the level of the shoulders, and all the exercises should be 
done more slowly and with less exertion. If the breathing becomes 
labored, or the countenance shows signs of interference with circulation, 
the child should rest until pulse and respiration return to their usual 
rate. 

Where deep respiration is an end in itself, in addition to the pre- 
ceding breathing exercises, others which favor involuntary deep breath- 
ing should be given. It is important that a good posture be maintained 
throughout. 

Exercises for Younger Children. — 1. Walking up-hill at a moderate 
pace without stopping. 

2. Running in place, i. e., executing a running movement without 
advancing. 

3. Distance running — from fifty yards to a mile. The minimum 
distance to begin with, and the maximum distance to work up to, in 
accordance with the general condition and age of the child. 

4. Running games, such as rolhng a hoop, playing tag, etc. 
Exercises for Older Children. — In addition to those just men- 
tioned : 

1. Games, such as hand-ball, basket-ball, tennis, and foot-ball as 
played by boys. 

2. Swimming for distance, when accompanied by a competent person 
in a boat. 

FLAT CHEST 

In flat chest the weight of the body is usually carried too far back, 
the abdomen and head being too far forward. The chest is flattened, 



816 



THE PRACTICE OF PEDIATRICS 



with ribs depressed, and there is interference with the proper expansion 
of the lungs. The shoulders often droop forward. The posture is one 
of general relaxation. 

Flat chest is of common occurrence among children during the years 
of school-life. It should be carefully corrected on account of the del- 
eterious effect on the lungs and abdominal organs. The necessity for 
its correction should be impressed upon the child. Attention to posture 
and breathing is essential. The aim should be to give exercises which 
will strengthen the muscles of the back and neck, deepen and broaden 
the chest, and increase its elasticity and breathing capacity. In addi- 




Fig. 125. — Back exercise. Raise head and chest high. 



tion to the exercises given under Posture and Breathing, I have found 
the following of benefit in these cases : 

1. Have the patient he prone on a hard, flat surface, hold the ankles 
while the patient raises head and chest as far as possible; the arms ex- 
tended and raised with the body, the backs of the hands being turned 
toward each other with the thumbs up. In the first few treatments, 
the thumbs may be clasped. Hold position for from two to five seconds, 
or while counting from one to five or ten. (See Fig. 125.) 

2. With knees straight, bend trunk forward until the hands touch 
the floor in front of the toes, or come as near to floor as possible, then 
raise the body to best possible standing position. Keep weight well 



KYPHOSIS 



817 



over balls of feet, raise the chest as high as possible, stretch the arms 
well down at the side; wrists, fingers, and elbows straight. Hold this 
position for from two to five seconds or while from five to ten are counted. 
The primary value of the exercise is in the elevation of the chest; sec- 
ondarily, the back muscles are strengthened, and, in bending forward, 
the muscles that elevate chest are relaxed so that they are better able 
to give a strong contraction when the body is raised. 

3. Have patient seated on a stool or low chair, and stand behind 
him. Patient swings straight arms forward upward to vertical, palms 
facing. He then turns palms forward and grasps your hands and pulls 
his elbows backward and doA\Tiward close to sides. As he pulls them 
downward resist his movement. 




Fig. 126. — Chest exercise. Stretch arms strongly. 



KYPHOSIS 

Kyphosis, as considered here, is an increase of the normal curve in 
the dorsal region of the spine, commonly called ''round shoulders," 
produced by weakened muscles and bad habits of posture, or some- 
times by improperly arranged clothing and by the occupation of the 
child. These causative factors should be removed as far as possible, 
and, as in all the deformities of childhood, attention should be given to 
posture, breathing, arrangement of clothing, etc. 

The treatment given under Flat Chest is appropriate here, as the 
two conditions are often associated. The following exercises may be 
added : 

1. Raise arms sideways to height of shoulders. Bend head back- 
ward with chin drawn in and at same time turn palms strongly upward. 



52 



818 



THE PRACTICE OF PEDIATRICS 



When patient has learned to do this well, as the head goes^ back the 
arms may be raised to vertical. 

2. Flex forearms upon chest, palms down and elbows well drawn 
back, shoulders level. Inchne head slightly backward and fling arms 
forcibly sideways. 

3. Raise arms sideways to shoulder level, turn palms up, make three 

short circles with arms, stop- 
ping with the backward 
movement. Raise arms a 
few inches, stretch out and 
up. Bring arms backward 
and downward to sides. (See 
Fig. 126.) 

4. Hanging Exercises. — A 
short curtain pole, 134 inches 
in diameter, may be placed in 
a doorway at desired height. 
Strong enough sockets can 
be obtained at a hardware 
store. 

(a) Hang with over- 
grasp. 

(6) Hang and swing. 

Hanging is of much value 
in kyphosis and flat chest 
on account of its effect 
upon the spine and spinal 
muscles. 

(c) Holding patient (see 
Fig. 127); trunk of patient 
resting against your body. 

(d) Holding patient; 
upper back resting only 
against body. 

Exercises "c" and ''d'' 
are used for the passive 
stretching of the lumbar 
and dorsal portions of the 
spine, the dependent part 
of patient's body acting as 
weight to stretch the spine. 
Hold from one-fourth to one-half minute. Repeat several times. 

5. Patient sitting on stool or chair with arms forward, midway be- 
tween horizontal and vertical, palms facing. Make resistance as arms 
are separated backward and downward. (See Fig. 128.) 

6. Forearms flexed upon upper arms, hands closed and facing the 
front of shoulders. Strongly rotate forearms outward and backward. 
(See Fig. 129.) 




Fig. 127. — Weight of pelvis and lower limbs to 
stretch the lumbar spine. 



KYPHOSIS 



819 



7. Patient sits astride a stool and raises the arms sidewaj^s. With 
an assistant, either the child's mother or nurse, on one side, and your- 
seK on the other, each grasp the patient's hand with one hand and place 
the other hand on his back in the region of greatest deformity. Have 
the patient pull the elbows close backward and downward to the sides, 
against resistance. At the same time gentle and firm pressure is made 
on the back. 

8. Patient sits on stool, places hands low on hips, fingers forward 
and wrists straight, elbow^s drawn well back. Let him bend forward 
from hips with back straight. Place your hands over the regions of 




Fig. 128. — Sit behind patient and give resistance on back of wrists as he separates 

his arms. 



greatest deformity and have patient raise the body against resistance. 
The back must be kept straight, head erect, and chest wtII arched. 
When the patient can do this well, his hands may be placed on the back 
of the neck, instead of on the hips. 

9. The patient stands, raises arms sideways, shoulder high; bends 
trunk forward from hips, back straight, and raises arms to vertical. 

10. Patient hes face dowTiward over end of couch or table, the whole 
body straight, hips and thighs only resting on table and held. Hands 
back of neck. Bend body forward until the chest touches the seat of a 
chair, then raise body as high as possible. (See Fig. 130.) 

11. While the patient is in dorsal recumbency, with one hand hold 



820 



THE PRACTICE OF PEDIATRICS 



his knees firmly to prevent his body moving and have the other hand 
under his shoulders. Have an assistant (any adult) draw the patient's 
arms as strongly as possible in a hne with his head and body, but away 
from them. Whien this is done, with the hand under the shoulders, 
gently but strongly raise his shoulders and body several inches from the 
table, hold while you count from five to ten, lower, and relax. Repeat 
from five to ten times. 

12. With children who are not strong begin with exercises in a re- 
clining posture: 

{a) Reclining position. Arms extended at right angle to the body, 

palms facing each other. 
Separate arms against re- 
sistance. 

(h) Rechning position. 
Arms extended beyond head 
in line with the body. Bring 
arms sideways, downward, 
against resistance. 

(c) Deep breathing. 

(d) No. 3 under Posture 
Exercises, but body arched 
only from hips upward, in- 
stead of from heels. 

In the treatment of 
kyphosis or flat chest with 
lordosis this exercise may 
be given. While a child is 
taking deep breathing or 
chest raising alone, lying in 
a dorsal position, with or 
without the shoulders being 
raised by some supporting 
object, place your hand 
under the small of his back; 
after the chest has been 
fully raised, have him en- 
deavor to press his back 
against your hand without lowering his chest. This may be done from 
50 to 100 times. Later, the same exercise may be done in sitting or 
standing positions, the lumbar region being pressed backward while the 
chest is elevated and forward. The lumbar spine should be brought 
back only until the entire back is in one straight Hne. 

The spinal muscles should be massaged4o make them pHable. 

SCOLIOSIS 

ScoHosis, or lateral curvature of the spine, is a condition in which 
the spine deviates in whole or in part to one side or the other of the me- 
dian line. It is accompanied by the rotation of the vertebrae, though 




Fig. 129. — Bring forearms back as far as possible. 



SCOLIOSIS 



821 



in some cases the amount of rotation is so slight that it is not easily de- 
tected; in other cases the rotation is marked in comparison with the 
amomit of lateral curvature. 

The treatment of curvatures resulting from such diseases as tuber- 
culosis or caries of the spine, rickets, etc., will not be considered, but 
only the simple curvatures which occur in cases of general debility, 
muscular weakness, or are the result of faulty habits of posture, a short 
leg, certain occupations, etc. 

Diagnosis. — In the treatment of scohosis, much depends upon a 
careful diagnosis. As far as possible all the etiologic factors should be 
ascertained: the heredity, general constitution, and temperament of 
the patient; the general appearance, condition of skin, the musculature, 
its structure and tonicity, should be closely scrutinized. The patient's 




Fig. 130.— -Movement may start from position of complete flexion or partial flexion 
with body resting on seat of chair or on shorter stand or table. 



habits of posture while standing and sitting, especially when he is un- 
conscious of observation, should be studied carefully. Inquiry should 
be made as to position during sleep, and if a school-child, concerning the 
desk and chair, and position while writing, etc. 

For examination the back should be ^ bared down to the level of the 
trochanters, when the height of shoulders, height and prominence of 
hips, position of the scapulae and their relation to the spine, the lines 
running from the tips of the ears to the tips of shoulders, and the posi- 
tion of arms as they hang at the sides, should all be noted. The posi- 
tion of the spine itself and its relation to points mentioned should also 
be closely observed when the patient is standing in his usual posture, 
and again when he is standing in his best possible position. The posi- 
tion of the spinous processes should be marked with a flesh pencil and 



822 THE PRACTICE OF PEDIATRICS 

the curve carefully studied out; the contour and relative size of legs 
should be noted and the feet should be examined. To ascertain the 
amount of rotation, the patient should be made to take the Adams 
position.* If any difference is found in the height of the hips, a careful 
measurement of the legs should be made. Another important point 
to be determined is the flexibihty of the spine, for to a great extent the 
diagnosis depends upon this. 

On the front of the body, the position of ribs, end of sternum, um- 
bihcus, and the tension of the abdominal muscles should be noted. 

Besides the above examination, it is well to inquire into the history 
of the patient, as to diseases of childhood, present ailment, liability to 
certain diseases, as to amount of exercise, both outdoors and indoors, 
and as to the condition of the digestive organs. Examine heart and lungs. 
Certain measurements may be taken, such as height, weight, height 
sitting, girth of neck, chest, waist, hips, biceps, calves and insteps, depth 
of chest and abdomen, and breadth of shoulders, chest, and waist. 

I have found the best method of recording to be by photographing 
the patient, using a thread screen, the spinous processes and lower bor- 
der of scapulae having been outlined with flesh pencil or dots of ink. 
To record the rotation, a lead tape may be molded across the posterior 
thorax at point of greatest convexity, while the patient is in the Adams 
position, and the tape carefully removed and its outline traced on paper. 

The curve may be a single long curve, a double or a triple one. En- 
deavor to find out which is the primary and which the secondary or 
compensatory curve, for the normal position of the spine is the result 
of the adjustment of the weight of the body around the center of gravity, 
in order to balance the body while standing or sitting, and if there is a 
change in the normal adjustment of the weight in one part, there must 
soon be a corresponding change elsewhere, so that if there is a left con- 
vexity in the lumbar region, there will be a compensatory curve to the 
right in the dorsal. 

In a well-marked case of scoliosis the child should be kept out of 
school for several months or a year. He should be allowed to retire 
early and sleep late, with a good rest at midday. 

Treatment. — The treatment should be both general and local. In 
the general treatment, carry out a thorough hygienic regime, which 
includes exercise in the open air, baths, attention to diet and bowels, 
clothing, and general light exercise for muscle-building and stimulation 
of the circulation, respiration, and digestion. One of the most important 
things is to train the habits of posture. 

The patient should be taught to lie on the side that will assist in 
straightening the curve, or upon his back in a good general posture. 

Special Treatment. — Massage and exercises which act strongly upon 
the spine itself, and suspension — (a) bar; (h) in Sayre's suspension ap- 
paratus, with and without pressure — I have found most useful. It is 

*Patient stands with heels together, knees well stretched, bends body forward 
from hips; head and arms hanging forward. 



SCOLIOSIS 



823 



occasionally beneficial for a patient to wear a plaster cast or leather 
jacket during the day between treatments. 

At first only general movements are given — those in which both sides 
of the body are used equally, such as the movements found under 
Posture and Breathing. A fittle later the exercises under Flat Chest 
and Kyphosis may be added, with simple movements of the body to 
strengthen the spinal muscles and make the spine more flexible. 

The folio Tvdng may be used: body-bending forward, backward, to 
right and to left, and body- 
twisting to right and left. 
These movements may be 
done sitting or standing, 
and with the hands at the 
hips, back of neck, or ex- 
tended over head. 

The bendings and twist- 
ings to right and left may 
be taken with stronger effect 
when the trunk is inclined 
forward from the hips with 
chest and head held well 
erect. 

In giving a new exercise 
the body should be bare, in 
order that the effects may 
be carefully noted. 

In giving corrective 
bending and twisting move- 
ments the bending should 
be toward the side of the 
convexity, with added pres- 
sure at the point of greatest 
curvature, and the twisting 
movement toward the side of 
the concavity, with pressure 
over the point of the con- 
vexity. The following are 
some of the special exercises : 
(Atypical S-shaped curve, 
convexities, right dorsal and 
left lumbar, has been taken 

to illustrate the treatment. These exercises can be reversed. A single 
or triple curve will have to be studied out with back bared.) 

1. Hanging from bar; pressure over convexities. (See Fig. 131.) 

2. Hanging from bar. Place your hand over point of greatest con- 
vexity, and push patient's body sideways. 

3. Hanging from bar. Have patient extend the leg corresponding 
to the side of lumbar convexity backward against resistance. 




Fig. 



131. — Spine being stretched by weight of 
body, pressure over convexities. 



824 THE PRACTICE OF PEDIATRICS 

4. Lying prone on table; left hand on neck, right on hip: raise body 
(see Fig. 125, but with hands placed in accordance with text). 

5. Lying prone on table; hands on neck. Carry patient's legs to- 
ward the convexity of the lumbar region. 

6. Patient sits astride a stool; hands back of neck. Twist body to 
left; make pressure over right dorsal region. 

7. Sitting on stool; left hand back of neck, right at hip; right leg 
extended backward. Bend body forward; resist patient as he raises 
body, using pressure over convexities. (See Fig. 132.) 



1 " "1 


■^ 


■ wS^B^H^^^^^^^ 




sH 


W) 


1 


j^Q 


^^^^^^^^«^H^~ . 


L 






L -MMlii 





Fig. 132. — Body raising with pressure over convexities. 

8. Standing: flex forearms on upper arms, with fingers pointing over 
shoulders. Extend left arm upward and right arm downward and back- 
ward, and extend left leg backward. 

9. Using wand, that is, about twelve or fourteen inches shorter than 
the height of the body ; grasp at ends, with elbows straight ; swing strongly 
from front of thighs to the right, sideways, backward, until the wand 
is at a perpendicular and in line with the spine. The body arches from 
heels to head. (See Fig. 133.) 

''Key-note position."* Left arm extended upward; right arm side- 
ways. (See Fig. 134.) 

* Key-note position is the position of arms by which the spine assumes its best 
position. 



EMPYEMA 825 

10. (a) Take "key-note position" standing. Stretch body for from 
two to five seconds. 

(6) Take '^ key-note position." Marching on balls of feet. 

Do not give more than three or four special exercises in any one treat- 
ment, and follow each of them Tvdth a marching exercise, such as 10 6, 
or some breathing exercise. 

EMPYEMA 

The indication for therapeutic gymnastics is the promotion of the 
recovery of the impaired function caused by the compressed lung, the 
adhesions present, and the contracted chest-walls. In the neglected 
cases we also have the sequelae in the deformed chest and spine, which 
should receive all possible treatment. 

The initial measures are those which may be permitted while the 
patient is yet in bed, and consist of posture and the lightest forms of 
exercise. The posture immediately following operation is that of lying 
on the affected side, for reasons of better drainage and immobility. 
When the necessity for this posture has passed, children who are old 
enough should be made to lie on the sound side for several hours each 
day. A good-sized cloth bag, partially filled vvdth bran or salt, properly 
covered, or a large roll of cotton, may be placed crosswise under the 
sound side of the chest during the exercise periods. This pad or bag 
further restricts the action of the chest on the sound side and increases 
the inspiratory action of the affected side. The exercises practised 
may be those of deeper or deep breathing, for from five to ten minutes, 
two or more times a day. Some authorities begin with deep breathing 
as early as the fourth or fifth day folloT\dng the operation. The effect 
of deep breathing may be increased by the arm on the affected side being 
held over the head or extended beyond the head during the deep breath- 
ing; or the arm may be raised to either position upon each deep inspira- 
tion. 

The Sylvester method of artificial respiration may be used once or 
twice daily, executing it very gently, depending upon the age of the 
patient and the condition present. The stretching of the extended arms 
may be prolonged; the child's body may be bent toward the sound side 
at the end of the inspiratory movement. 

During breathing exercises, while the patient is lying on the sound 
side, place your hand under the body; gently raise it as he inhales. 

Some writers urge the rule of getting the patient up as soon as pos- 
sible after a week of exercise in bed, as the ensuing exertion is a desirable 
aid in lung expansion. We may still, however, have the child take a re- 
cumbent position while he takes his breathing exercises. T\Tien the 
child's streng-th warrants, the deep breathing exercises may be practised 
while he is sitting and standing. 

Osier refers to Naunyn's exercise, patient sitting in an arm-chair 
wdth sound side bending over arm of chair, grasping a rung. While 
holding the rung, forcibh^ inhale. The same effect is obtained when the 
deep breathing exercises are combined "^ith the various lateral bending 



826 THE PRACTICE OF PEDIATRICS 

movements of the body to the sound side, with or without the added 
combination of arm movements, or the use of the arm only on the affected 
side. The various breathing exercises should be practised from ten 
to thirty minutes a day, each exercise being repeated from 5 to 20 times. 
To avoid overtiring, give a short rest after every two or three minutes 
of exercise. 

Exercises. — Standing. — 1. Deep inhalation, full exhalation, arms 
hanging. 

2. Deep inhalation, full exhalation, hands back of head. 

3. Deep inhalation as arms are raised sidewise, shoulder height. 
Exhale as arms are lowered. 

4. Deep inhalation as arms are raised sidewise overhead, elbows 
straight. Exhale as arms are lowered with bent elbows. 

5. Flex wrists, but keeping elbows straight; repeat No. 4. In the 
following exercises the one hand or arm refers to the one on the affected 
side: 

6. No. 2, one hand only back of head, other arm by the side. 

7. No. 3, only one hand being raised, other by the side. 

8. No. 4, only one arm being raised, the other by the side. 

9. No. 5, only one arm being raised, the other by the side. 

10. With the hand in position, as in Numbers 6, 7, 8 and 9, inhale 
deeply, bending toward the sound side. 

11. Nos. 6, 7, 8, and 9 to be executed, while carrying the arms to 
position and at the same time bending the body toward the sound side. 

12. Charge to front with leg on affected side (long stride, bending 
knee). Bend body, touch floor in front of toes with corresponding hand. 
Flex wrist, with straight elbow, raise arm to overhead position, at the 
same time inhale. Exhale as you bend forward again to floor, with 
flexed arm. Repeat from three to flve times. Step back to position. 

13. Charge to side, inhale as you raise arm sidewise to overhead and 
bend body to the sound side; exhale as you straighten body and lower 
arm; repeat three to five times; step back to position. 

During this stage of treatment one or another of the following meas- 
ures, Y^hich have been recommended by the various writers, may now 
and then be used for from five to ten minutes of the exercise period. 
These are: blowing bubbles and various wind instruments, use of the 
spirometer and of Wolffe's or James' bottle apparatus. Their use should 
be limited to adding variety or interest to the treatment of the 
child. 

As the patient's strength increases the various out-of-door exercises 
and games which more strongly stimulate the circulatory and respira- 
tory apparatus should be made use of. These are: fast walking, hill- 
walking, rope-skipping, — backward as well as forward, — running, 
horseback riding, bicycle riding, the various games of tag, ball, and swim- 
ming — breast and back stroke preferred — for distance and speed. These 
exercises should be done with the chest expanded and head erect. Ten 
to twenty minutes of the breathing exercises should be kept up in addi- 
tion to the out-of-door exercise, as long as the case needs treatment. 



EMPHYSEMA 



827 



After exercising, a patient should always rest from twenty to thirty 
minutes in a reclining position. 

If the case presents a possibility of the formation of scoHosis, a tho- 
racic support should be worn in the intervals between the treatments, 





Fig. 133. — Swing strong- 
ly to this position without 
bending elbows. 



Fig. 134. — Key-note position. Arm corresponding 
to low^ shoulder is raised. Used to maintain a better posi- 
tion of the spine during certain exercises and marches. 



which w^ould keep the trunk in a straight line without interfering with 
the respiration. The use of a bar and suspension apparatus each day 
for from five to ten minutes is also advised as a preventive measure. 

EMPHYiSEMA 

While the physical changes of emphysema are usually not marked in 
children, ten to twenty minutes a day of the follomng exercises will 
prove of benefit, even in such cases. 



828 THE PRACTICE OF PEDIATRICS 

The patient should avoid strain or overfatigue. 

In order to facihtate exhalation without alveolar strain, all forced 
exhalations produced by exertion or used as special exercises should be 
done with the mouth open. 

While expiratory exercises are indicated in emphysema, inspiratory 
exercises are also of value, as they aid in maintaining the functional 
power of the unaffected portions of the lungs, and in consequence the 
patient suffers less from dyspnea. 

In marked cases of emphysema the breathing is mainly diaphrag- 
matic. Any impairment of, or interference with, the action of the dia- 
phragm brings on dyspnea. Practice and improvement of abdominal 
breathing are of value. 

A distended or bulging chest-wall may be supported by a tight elastic 
band covering the ribs from the axilla down. 

Frequent short periods of rest in bed lessen the accumulative prod- 
ucts of exertion. 

Respiratory Exercises with Manual Aid. — 1. The Sylvester and 
Satterthwaite methods of artificial respiration may be used from two to 
five minutes twice a day. Expel as much air as possible by pressure. 

2. Patient lying on his back, stand by his side with your hands on 
either side of his chest. After he has inhaled as completely as possible, 
he slowly exhales through the open mouth; at the same time presses 
alternately with hands from the base of his lungs to the apices. He 
ejaculates ^^ah!'' with each pressure until his exhalation is completed. 
Practise five to ten minutes a day. 

3. Gerhardfs Method. — ^With your hands on the side of patient's 
chest, press both sides of the chest as the patient exhales ordinarily. 
Repeat 20 times per minute for ten minutes, three or four times daily. 

4. McKenzie's Method. — ^With a four-inch support (roll of cloth) 
under patient's lower thorax, his hands under his head, and his chest 
expanded in inhalation, facing the patient's chest press both sides of 
his thorax, the patient exhahng at the same time. Repeat 10 times a 
minute from two to four minutes. 

Active Exercises. — Deep Breathing {Standing). — 1. Inhale as arms are 
raised sideways upward, elbows straight. Exhale as arms are lowered 
sideways downward. Repeat 5 to 10 times. 

2. Inhale as arms are raised forward upward, elbows straight. Ex- 
hale as arms are lowered forward downward. Repeat 5 to 10 times. 

3. Arms overhead. Exhale as you bend forward and touch floor. 
Inhale as you raise upward and bring arms to position overhead. Re- 
peat 5 to 10 times. 

4. Sitting, inhale through nostrils as much as possible; lean a little 
forward as you exhale through the mouth. Repeat 5 times. 

5. Lying on back — abdominal respiration. Hands back of neck; 
draw as much air in as possible through nostrils; the abdominal wall 
expanding forward throughout the inhalation, the upper thorax not ex- 
panding; exhale. Practise the abdominal respiration also while sitting 
and standing. Repeat 5 to 10 times in each position. 



CONGENITAL ATAXIAS 829 

Development of the Accessory Muscles of Expiration. — Thoracic — 
1. Standing Position. — ^Arms flexed, hands at the sides of the shoulders, 
strike strongly the ulnar borders of the hands together, in front of chest. 
Repeat 10 to 25 times. 

2. Arms extended sideways, shoulder height. S^^dng arms strongly 
forward, crossing each palm slapping the opposite shoulder. Repeat 10 
to 25 times. 

3. Arms extended overhead. Full arm circle. Arms crossing in- 
ward as a swing is made strongly downward and up sideways to over- 
head. Repeat 5 to 15 times. 

Abdominal. — 1. Lying on Bach. — Raise body to sitting position. 
Repeat 2 to 5 times. 

2. Raise both legs up to a perpendicular position without raising 
the hips from the floor. Repeat 2 to 5 times. 

3. Flex both thighs upon abdomen, the legs being flexed on the thighs 
at the same time. Repeat 2 to 10 times. 

4. If Nos. 1, 2, and 3 are too difficult, then alternate raising; right 
leg to perpendicular, lower; left leg to perpendicular, lower. Repeat 
6 to 20 times. 

The exercises should be practised t^vice a day. Beginning wdth 
fifteen minutes, the time may be extended until the patient is taking 
thirty minutes twice a day as he becomes stronger. Better exercise 
slowly. When beginning to tire, rest for a few minutes. 

Compressed-air Bath and Rarefied Air Apparatus. — ^These methods 
of treating emphysema have been of value in treating adults. They 
are not practical wdth young children. If apparatus is accessible, they 
might be tried with older children. Exhalations into a rarefied air ap- 
paratus increase the amount of air exhaled and make the breathing 
easier. The Waldenberg apparatus is one of the best. The compressed 
air bath, while apparently not as suitable a measure of treatment, has 
really proved of greater benefit, in that it benefits by aiding in the re- 
moval of the causes of emphysema, viz., bronchial catarrh and spasm. 
It increases the vital capacity and respiratory force. A course of from 
20 to 30 baths are usually given, each bath lasting two hours; during 
the first half -hour the pressure is increasing and then the maximum pres- 
sure is maintained for an hour, and during the last half-hour the preS' 
sure is gradually reduced to normal. The lessening dyspnea and gen- 
eral benefit derived from a course of baths remain for a considerable 
period of time after such a course has been finished. 

CONGENITAL ATAXIAS 

The ataxias of childhood, to which we refer, are hereditary cerebellar 
ataxia and hereditary spinal ataxia. Most observers have described 
them as beginning to develop at the age of eight or ten years; one or 
two observers have mentioned a much earlier period, stating that the 
symptoms generally appear at the age of three or four years, and that 
the cases may be congenital. 

Cases upon which this treatment is based were congenital; the de- 



830 THE PRACTICE OF PEDIATRICS 

velopment of the physical movements was retarded and defective 
from the beginning, and in one case of hereditary spinal ataxia the phy- 
sical act of nursing was also defective. 

Hereditary cerebellar ataxia is characterized by the involvement 
both of the upper and lower limbs at the same time, although the upper 
limbs may not be ataxic to the same degree as the lower. The gait 
is reeling, uncertain, with the feet wide apart, body bent forward, the 
weight of the body being supported mainly upon the balls of the feet, 
the toes inclining inward, locomotion at times being interfered with by 
the crossing of the legs. One leg is usually more ataxic than the other. 
The reflexes may be increased. The speech is hesitating, defective, and 
explosive, but audible. 

Hereditary spinal ataxia {Friedreich's ataxia) is characterized by its 
beginning in the lower limbs, gradually extending to the upper limbs, 
and finally involving the organs of speech. The symptoms are vertigo; 
swaying from side to side on standing; marked inuscular weakness, 
especially of the extensors and abductors (paralysis may follow); con- 
tractures of the flexors and adductors; scoHosis and talipes resulting, 
first, postural, through muscular weakness, later becoming fixed; rheu- 
matoid pains; and diminution or loss of the patellar reflex. The head is 
held to one side in a clonic spasm, but turns from one side to the other 
every day or two. One leg is more ataxic than the other. The move- 
ments are characterized by rigidity and incoordination; the articulation 
is scanning and explosive, and oftentimes, for days, the patient cannot 
speak above a whisper. 

Dana states that there may be a mixed or transitional hereditary 
cerebellar and spinal ataxia. 

Some observers state that there is defective mentality, and that the 
patients possess a violent temper. I have not found either to be true — ■ 
the temper being no different from that which one would find in a little 
patient otherwise ill for as long a period, and who was not perfectly 
understood. The speech, or the poise of the head, may suggest deficient 
mentality, but I have found these children affectionate, observing, and 
rational, and showing hereditary indications of brightness in mechanical^ 
mathematical, or methodic lines. 

In beginning treatment, study the patient's capability for coordinate 
action. Do this throughout the entire course. When you have de- 
cided upon the exercises to be given, show them to the patient in detail, 
explaining them fully, so that he may understand what effort is required, 
and occasionally, in teaching, repeat these illustrations and explanations. 

Accuracy is of the first importance. If there is lack of control in 
movement, pause and hold patient in correct position while you count 
from one to four or ten before resuming movement. Follow that prac- 
tice as long as it is necessary, and at every tendency toward losing con- 
trol. Slow and accurate work first, later more rapid work. 

While learning an exercise of coordination permit patient to use his 
eyes to watch his limbs, in order that the coordinate centers may thus 
be reinforced or aided. Next rely only upon his muscular sense for 



CONGENITAL ATAXIAS 831 

correct execution, and at last have the eyes closed in order to eliminate 
the relationship of surrounding objects, which might aid in the execution. 
A reclining posture is assiuned for coordinate training, where the patient 
is unable to stand. 

Do not expect a child to cooperate with you in attention or efforts 
to make his physical movements accurate when he is left to himseK, for 
it is rarely done. The coordination must become reflex. The training 
must be carried to the extent of unnecessary capability. ''The keynote " 
must be, as with the orthopedist, overcorrect, for the correct execution 
of work under observation would not be sufficient to insure coordinate 
action the moment a child attempts to do things alone, or when he is 
tired, or when his attention is given to other objects. 

The aim in treatment should be in keeping with a child's natural 
sphere in life. Childhood is the time of muscular activity and growth; 
it is the period of play and games. When a child is able to play at all, 
if left to himself he will not stop for rest, when he begins to tire or fall; 
he will do so only when the game is ended and his companions finish. 
Play, therefore, serves only to increase the incoordination, because of 
overexertion. To make a child capable of walking or running at all, 
makes him eager to play when others play; but it is like the fencing or 
boxing of two men, one of whom completely outclasses the other, whose 
native quickness and strength are completely overcome, so that he has 
neither the opportunity to show them nor the mind to use them. The 
ataxic child, in playing with normal children, besides tiring more quickly, 
being outclassed, becomes bewildered and cannot seize the opportunity 
to attempt coordinate action. 

No satisfactory results can be expected from the treatment of ataxia 
unless it is continued until the child is able to play as well as other chil- 
dren. The treatment should be made practical as soon as possible. 
Do not spend unnecessary time on gymnastics or apparatus. When a 
child shows that he is able to take one step, begin walking exercises, 
going up and down stairs, and running. 

Study the patient's movements, and analyze his defects in execu- 
tion. To tell a child not to fall when he is walking, and expect him to 
be able to avoid falling, is not fair to the child. He does not know why 
he falls, and his attempts to avoid it only increase his general nerve 
tension. His falling may be due to one of several causes: it may be 
that he is walking with his feet widely separated; if so, he gets but little 
support from the advancing foot, and upon fatigue, diverting of atten- 
tion, or striking a small obstacle, he Tvdll fall. When he permits his feet 
to separate, he should at once be directed to keep them close together. 
By so training the child it will become easier to keep his feet in position, 
and, if there is no other defect, falhng mil unconsciously be avoided. So 
all of his work must be analyzed to discover its weaknesses or defects. 

General gymnastics have no place in the treatment of ataxia, but 
where certain groups of muscles are weak, movements may be given to 
strengthen them, in order that they may do their part in coordination. 
Throughout the greater part of the treatment I have used exercises for 



832 THE PRACTICE OF PEDIATRICS 

strengthening certain groups of muscles, although their primary value 
was not to improve coordination. It is well to have these movements 
executed against resistance, in order to determine the amount of muscu- 
lar power the patient possesses. 

Coordinate efforts at balancing and walking are first made upon 
the floor until the child shows a little improvement, but it is difficult 
to make a child realize the necessity for using all of his energies in the 
effort, when he knows that there is no particular danger; therefore ap- 
paratus is necessary to force coordination. Boards, blocks, and ladders 
(see Fig. 121) are used, not for the purpose of developing ability toper- 
form exercises upon them, but to develop unconsciously the habit of 
constant care and watchfulness, as the child can readily appreciate the 
fact that, without such precaution, he will slip and fall ; and also learns 
that he cannot relax, whenever he is inclined to do so, as he might were 
he on the floor. By this apparatus work, children unconsciously ac- 
quire the ability to control themselves in places of danger into which 
their play leads them. 

Always place some incentive before the child as otherwise he rarely 
puts forth the necessary exertion. His interest, attention, and muscular 
and nervous energy must be exerted. Tell him that it is necessary to 
do a certain amount of work before the treatment is over; that, when a 
certain amount is done, the treatment for the time will be over, whether 
the hour is up or not. Tell him that he must do something more than 
he did the day before, whether it takes longer than the hour or not. If 
it takes longer than the hour, he will learn that you mean what you say, 
and sometimes the entire work of the hour will be executed in the last 
few minutes, despite the fact that the fatigue of the previous efforts 
makes it more difficult. 

While we wish to avoid fatigue, a certain amount is harmless. If a 
child remains fatigued at the end of an hour's rest, following the treat- 
ment, and he does not coordinate as well as before the treatment, pro- 
vision should be made for more rest during the next treatment. A 
child's inertia needs to be overcome in spite of fatigue. The treatment 
will teach him that merely saying he is tired will not enable him to escape 
the work. This has been impressed upon me by seeing how, after fifty- 
five minutes of unsuccessful effort, a child will ''pull himself together," 
as it were, and do a new exercise that may really be difficult, in order 
that he may be able to leave at the end of the hour. 

Never permit a child to suffer a fall or injury during the treatment. 
Never take any risks with your patient. (See Fig. 135.) Falls cannot 
be prevented in ordinary walking or running, except by words of cau- 
tion, which should always be used; however, they should not be used 
in tests when the patient is endeavoring to see how far he can walk or 
run before he falls. On the first fall, make him return. 

Experience teaches a patient distrust of his ability to do a thing 
which he has never tried, or, having failed after several trials, he will 
naturally say he cannot do it, and not wish to attempt it. Confidence 
must be inspired in him to follow directions unhesitatingly by insisting 



CONGENITAL ATAXIAS 833 

upon his accomplishing every task given him, and thus proving his abihty 
to do it, and also by showing him that his interest is yours, and that 
you have never permitted him to be injured during his unsuccessful 
attempts. 

With a child it is not enough to secure coordinate action, but you 
must secure endurance along the lines of reflex, coordinate action. Co- 
ordinate action with one who is ataxic calls for general tension, and the 
unnecessary accessory action of groups of muscles is fatiguing, and re- 
suits in excessive waste of nerve and muscle energy. To teach a child 
to do his work easily and to carry on prolonged coordinate effort is thus 
accomplished by the same means. A parallel can be found in a person 
learning to skate or swim. Here we have a general tension and the gen- 




-Walking on a narrow board several feet above the floor. An advanced 
exercise in coordination. 

eral action of all the muscles of the body — a great waste of energy to 
prevent one from falling, or going under the water — and even after one 
has learned how to swim, much of that nervous waste of energy will con- 
tinue until he has thoroughly mastered the art. Endurance and con- 
servation of energy are very desirable in an ataxic. 

After he had been in training for several months one patient walked 
forward, without stopping, five hundred feet on the top of a fence, and 
backward one hundred and twenty feet without stopping. The same 
child walked several miles up and down a mountain-side without stop- 
ping, his mind occupied with observation and not applied at all to his 
walking, save in response to caution. He was able also to run half a 
mile without stopping or falling. It is not for the purpose of making 
53 



834 THE PKACTICE OF PEDIATRICS 

the child a long-distance walker or runner that, after he has learned to 
walk or run properly, the distance is gradually increased to one or more 
miles, telling him to "take it as easy as possible" without stopping, 
although when fatigue is noticed sufficient rest should be given. It is 
common to see normal children of three or four years of age run and play 
for long periods of time without apparently tiring — our object in en- 
durance exercises is to fit the patient for a child's sphere in life. Grad- 
ually the muscles become inured to fatigue, do their work with a mini- 
mum expenditure of force, and to a certain extent recuperate while in 
action. 

Short periods of retrogression must be expected occasionally through- 
out the entire course. When a child is tired, has had excitement, or 
when he is indisposed, one must expect a temporary loss of coordination. 
Parents too should be prepared for this, and not be disheartened when 
it occurs. 

The life of an ataxic child should be quiet and free from excite- 
ment. Judgment should be used in allowing him to mingle with other 
children, even though they are members of his own family. When 
allowed to play, it should be with younger children, if possible, or with 
his nurse, or mother, until the time of playing with other children is 
made a part of the treatment, and even then it should be confined to 
lines permitted by the one in charge. In the intervals, a child needs 
sufficient quiet and rest, so that he will completely recuperate and be 
in the best possible condition for the next treatment, as the treatments 
afford the only hope of restoring him to nerve stability and normal mus- 
cular movement. As he improves, however, the daily regime should 
vary. As a rule, a child should rest, lying down from one-half hour to 
an hour before treatment, and the same length of time after treatment, 
and, in fact, at any time during the day when incoordination becomes 
marked. 

Attention to the general health of the child is important. There 
should be a simple and nutritious diet, careful attention to the bowels, 
daily bathing, an outdoor life, the treatment being taken whenever possi- 
ble in the open air. These things should not be neglected, as these pa- 
tients are apt to have less resistance to disease than non-ataxic children. 

Illness does not cause a retrogression except temporarily through 
the weakness which follows it. With returning health and strength, 
progress continues. 

Cooperation is important. It is more necessary here than in any 
other chronic ailment. A child will recover in one-half the time if co- 
operation is conscientiously given by those in charge of the child. For 
illustration: the child is capable of walking, but walks on the balls of 
his feet, or crosses his feet frequently, which causes him to lose his 
balance easily; whenever he does it, if he is called back, no matter what 
his object may be for going, until he has walked across the floor correctly, 
the next time he starts to walk it will not be necessary to call him back as 
many times, and the constant correct walking will gradually make it a 
reflex habit. If he is permitted to walk incorrectly, it encourages inco- 



CONGENITAL ATAXIAS 835 

ordination and a careless habit. The course of nervous stimuli has been 
likened to the making of a new path in a jungle. Constant use will make 
it easy to travel, but if the old path of incoordination is used instead, 
the new path of coordination remains a difficult task for a much longer 
period of time. The lines of least resistance are followed, and the new 
path must be made as easy as the old if we would have a child use it. 

Treatment should be for an hour daily. More than an hour's treat- 
ment is apt to produce general nervous fatigue. An ataxic child may 
need training along many lines, and the attempts to do one thing cor- 
rectly may require so long a time that it is unwise to attempt to give 
work for the correction of all at one treatment. If this is attempted, 
nothing will be well done in the hour, and the work ^dll only serve to 
tire the patient and increase the incoordination. It would take a normal 
person, who could do the movements well, more than one hour to cover 
all the lines with improvement in each. An hour has been spent in 
endeavoring to walk a plank once without falling off, but the child did 
it before the treatment was completed, and the next day he did it twice, 
so there was evident progress. When one morning hour is given to the 
lower limbs, work might be mapped out so that an assistant, the mother 
or nurse, could give another hour, or half hour, in the afternoon to ex- 
ercises for the arms and fingers, or to massage, which would improve the 
nutrition of the tissues and the general circulation, so as to insin-e a 
better general response of the nerves and muscles. Another half -horn* 
could be spent in training the speech of the child. In this way the cor- 
rection of the upper limbs and speech could progress at the same time 
as that of the lower limbs, instead of waiting until after the coordination 
in the lower limbs is first secured. 

Improvement in one line does not imply any special improvement 
in another. Walking, running, going up and down stairs, jumping, and 
hopping must each be taken up separately. It is particularly true, in 
case one is working for improvement in the lower limbs, and little at- 
tention is given at the same time to the upper. At the end of the time 
devoted to locomotion, the ataxia of the upper limbs is but little im- 
proved. 

Parents and physicians occasionally think that a child will outgrow 
his ataxia, but this is a mistake. 

A patient should hold as good a posture as possible at all times, as 
the weight of the body is then better adjusted. One or two exercises 
under Posture should be added to the treatment. The suggestions about 
clothing, under Posture (p. 807), are especially valuable here. 

Five or ten minutes once or twice a day should be devoted to a sit- 
ting posture in which the body is held erect, but the hmbs relaxed, and 
every part of the body entirely at rest. This aids greatly in overcoming 
the nervous instability and irritability, and is a valuable help in securing 
general nervous control. 

When the patient is given his treatment there should be no one else 
in the room, unless it is one whose presence would aid in securing better 
attention or work from the child. 



836 THE PRACTICE OF PEDIATRICS 

There is a difference in the treatment of congenital ataxias and that 
of locomotor ataxia: In one case the patient is a child, in the other an 
adult. With the child, between treatments there is little or no coopera- 
tion; with an adult there is cooperation. During the period of develop- 
ment a child's sphere is that of play and muscular activity. The adult 
looks forward only to returning to his business or professional activity, 
and stops treatment when his proficiency and coordination permit this. 

Exercises. — In the beginning, when the child cannot walk, exercises 
should be taken while lying down. For the lower limbs, they consist 
of coordinate flexions and extensions, abductions, adductions, and cir- 
cumductions, actively and against resistance, and of touching certain 
designated points or objects with the feet separately. In cerebellar 
ataxia one can more readily advance to the standing exercises, and take 
foot-placings (floor may be marked for this), stepping out to side, front 
and back to the ordinary oblique positions, forward and backward. 
The weight of the body is carried by the advancing foot, so that when 
the movement is completed the weight rests equally over both feet. 
Taking a step is now practised, bringing up the other foot to the side of 
the foot advanced. This is done sideways, forward, and backward. 
Two or three steps are now attempted, a pause being made after each 
one until a perfect poise of the body is obtained. This is continued until 
the child can walk across the room. At this time the defects shown in 
the walking should receive attention. 

The defects in walking or running are usually the following: carry- 
ing the weight of the body too far forward; not straightening the knees 
completely; the reeling gait; the crossing of the legs; walking with the 
feet separated; turning the toes inward; not lifting the feet sufficiently; 
not bringing the heels to the ground. As occasion arises, show the child 
his defects, and caution him against their repetition. In walking and 
running in the room, repeat the exercise if any faulty execution is noted. 
Instruct the members of the household, who have charge of the child, 
never to ignore these defects, but always to insist upon their immediate 
correction. In the outdoor walking or running, the patient should 
always be in advance of you, so that his every movement may be ob- 
served. It is here that the correction of the defects should mainly take 
place. The following four movements aid in correction, and should 
be given every day for quite an extended period, in order that the weak- 
ened muscles may be strengthened for the required work of coordination: 
(a) Drawing up the knees against resistance. 
(6) Flexing the feet against resistance. 

(c) Abduction of feet against resistance. 

(d) Extension of legs against resistance. 

In the full extension of the legs, the feet must be kept flexed. 

When the child is able to walk across the room, work is begun upon 
the apparatus: boards from 7 inches down to 1 inch in width by half 
an inch in thickness and 10 feet in length, of well-seasoned hard wood; 
a ladder, the sides of which are IK by 2}^ inches, 10 feet in length, and 
the rounds % inch in diameter by 12 inches long, placed 10 inches apart 



CONGENITAL ATAXIAS 837 

in the ladder; 24 blocks of wood, 2 inches in thickness and 12 inches 
wide by 14 inches long. Beginning with the 7-inch board, have the 
child walk over and back, with the arms in different positions, the eyes 
open and the eyes shut; one end of the board placed upon one block, 
and so on until one end is resting upon ten or more superimposed blocks. 
The board is placed upon supports of equal height, beginning with one 
block under each end, increasing the height until the board is about 
five feet from the ground. At each increase in height the various ex- 
ercises are repeated. (See Fig. 136.) Two five-inch boards can be used 
when placed upon the same supports, the boards being about eight or 
ten inches apart. The child can step from one board to the other, going 
from one end to the other; and, standing in the center, he can step for- 
ward and backward from board to board. With boards placed together, 
walk forward and backward, the boards bending unevenly as one foot is 
on each board. 

Using the blocks alone, arrange them for walking, at varying dis- 
tances from each other; also make piles uneven in height, and have 
patient walk on the blocks with the eyes open and the eyes shut. 

Ladder Exercises. — Ladder flat on the ground, walk forward in the 
spaces between the rounds; walk sideways and walk backward. Place 
one end of the ladder upon a block and add blocks gradually until 
the ladder reaches the height of the child's knee; then begin with both 
ends of the ladder placed on single blocks, gradually increasing the height 
until the ladder reaches the height of the knee; after each change of 
height the walking exercise forward, sideways, and backward is repeated. 
When using the blocks the child may bring them from the pile and build 
the steps that he is to walk upon; standing upon the block previously 
placed upon the floor, he bends forward, placing in position the one he 
carries, repeating the process until all the blocks are arranged. When 
through walking over the blocks, he stands on the one next to the last 
one placed, bends over and picks up the last one, and may carry it back 
to the pile, walking over the blocks, or he may lift and raise it above the 
head, and pass it, either forward or backward, to you. The block may 
be carried by the child walking through the spaces of the ladder, and 
both ladder and blocks may be arranged in various forms to be walked 
over by the child. 

You may now take up the balancing work, where the weight of the 
body is carried on only a portion of the sole of the foot, as in walking 
on the rounds of the ladder. The ladder is first placed flat upon the 
ground, and the walking is done forward and backward. This is graded 
by raising one end of the ladder until the child can walk up and down 
on the rounds several times without a mistake, the ladder raised to an 
angle of 35 degrees. (See Fig. 136.) 

In beginning the treatment, the child is instructed not to allow 
one foot to step directly in front of the other. By this time coordination 
is sufficiently mastered so that balancing as an exercise may be taken up, 
using the boards from 2 inches down to one inch in width. On these 



838 



THE PRACTICE OF PEDIATRICS 



boards the child must place one foot in front of the other, and walk for- 
ward across it; next, walk backward, eyes open and eyes shut. 

When a child is able to walk 50 or 60 feet without falling or stopping 
to rest, the distance is gradually increased in outdoor walks, correcting 
defects when noticed, until he can walk a mile or more without their 
occurrence or without falling. 




Fig. 136. 



-Walking on rounds of ladder, one end raised several feet above floor- 
advanced exercise in coordination. 



-an 



When the patient is able to run across the room in a straight line, 
teach running in a circle. Watch closely his running and do not allow the 
feet to be widely separated, or the weight of the body to incline too much 
forward. He should run with a firm stride and raise his feet well. In- 
crease distance until he can run half a mile without falling or stopping to 
rest. Later, teach running up and down hill; running short distances, as 
from 80 to 100 feet, as fast as he can, and stopping without faUing; trying 
to catch a person; racing with another child, who starts at a sufficient 



CONGENITAL ATAXIAS 839 

distance behind him, so that they will finish at about the same time ; run- 
ning to catch a person who will dodge and run zigzag and in circles. 
playing with other children in running games, such as "cross-tag," 
"pull away," etc., having the other children so handicapped that by 
exerting himself to the utmost he T\dll not be caught. During these 
games, if he falls, he should be obhged to run around the grounds once 
alone. 

Other indoor exercises are: whirling on one foot 50 times -without 
falhng; repeat on the other foot; alternate thus with, eyes open and eyes 
shut; running in a short circle 50 times without falling. Such exer- 
cises are helps to the running out-of-doors. Another helpful exercise 
is running several hundred feet out-of-doors, whirling around in the 
direction indicated without falhng whenever the command "turn right," 
or "turn left," is given. 

Walking Up and Down Stairs. — Begin with one or two steps and 
gradually increase until the length of the fhght is reached, seeing that 
the feet are not separated, but that they advance in straight fines di- 
rectly in front of the body. In walking. up stairs, carry the weight of 
the body over the foot that is on the upper stair. In walking doT\Ti 
stairs, be sure that the heel is brought against the back of the stair, so 
that the foot at no time will rest on the edge. Keep the hands close to 
the sides of the body while walking up and down stairs with the eyes 
shut. Run up and down stairs with the eyes open and again vnth. eyes 
shut, carrying articles while running. One should alwaj-s be near 
enough to the child for his protection in case of accident. The object 
is to train the muscular sense and make the coordination sufiiciently 
reflex to enable the child to run or walk up the stairs alone without 
the danger of an accident. 

Jumping. — Draw a line with a piece of chalk; teach the child to 
incfine his body slightly forward, bending knees a fittle, spring forward, 
aided by an upward sT\dng of his arms. Jump for height and distance 
over the rounds of the ladder, from one space to another, and repeat, 
skipping one space. Jump from block to block, the blocks being sepa- 
rated at var^^ing distances. Jumping over blocks; running and jumping. 

Hopping. — Hopping is much more difficult, as the spring is from 
one foot alone, and the landing on the same foot. In addition to the 
coordination necessary to balance upon one foot, are added the required 
effort to lift the body from the ground and the coorcfination required 
for balancing the body on landing, so as to avoid falhng. The training 
is about the same as in jumping; hopping with either foot over a string; 
hopping for distance; hopping for height; and making a succession 
of hops on the same foot, "wdthout touching the other foot to the gTound; 
the running hop. 

At the close of these exercises it may not be amiss to repeat what 
was stated at the beginning, that it is not desired to make the child an 
athlete, but distance walking, distance running, fast running, jumpuig, 
and hopping are exercises which children use in their pla}^ for long pe- 
riods of time, and the coordination secured by the apparatus work is 



840 THE PRACTICE OF PEDIATRICS 

often of value in places of danger, where their play is often apt to lead 
them. Coordination to this degree should be secured. 

Exercises for the Upper Limbs. — In the beginning, the general move- 
ments of the fingers, wrists, forearms, upper arms, and shoulders may 
be practised, executing them slowly until the coordination is perfect in 
these movements. The above exercises are simple movements of flexion, 
extension, rotation, and circumduction. The educative movements, 
however, have mainly to do with the fingers : 

1. Flexing and extending the fingers. 

2. Slowly and gently touch the tip of the thumb to the tip of 
each finger and hold them together without pressure while five is 
counted. 

3. Simultaneously touch the tip of each finger to the tip of the 
thumb. 

4. Flex strongly the index-finger so that the end will touch the base 
of its second metacarpal bone. 

5. Flex strongly and adduct the thumb so that the tip of the thumb 
will press the tip of the little finger. 

6. Flex strongly and adduct the thumb so that its tip will press the 
base of the little finger. 

7. Needles: have them graded from the largest to the smallest size, 
grasp a fine thread between thumb and each finger of one hand in turn, 
and thread each needle; repeat, using the other hand. 

8. Buttons: have them graded from the largest to the smallest ob- 
tainable, and have them sewed on to one strip of cloth, another strip 
of cloth having buttonholes to correspond. Practise buttoning and un- 
buttoning with thumb and index-finger of each hand. 

9. Pins: picking them up with fingers. Pick up the pins and press 
them through a stiff pasteboard box, forming various designs. 

10. With a pencil correctly held, make squares, triangles, parallel 
lines, etc., with and without dots as a guide. 

11. With a pencil correctly held, make figures and letters, both large 
and small. 

The child can also use the exercises of piling coins and chips, touch- 
ing hanging balls, placing pegs in holes, and similar games. Also throw- 
ing and catching a 'ball. A child should be made to dress and undress 
himself, and to feed himself, although as exercises, at the beginning, he 
may do them only in part. 

In eating, the spoon or fork should never be full, and the cup or glass 
should be only partly filled. The execution of the movements should 
be slow. 

For incoordination of the neck muscles (more often a part of choreic 
ataxia) the shot-bag exercises (p. 811) are of value. They should be 
preceded by a course of simpler exercises. 

Exercises for the Speech. — A child should be taught to enunciate 
numbers and letters distinctly. An interesting book should be read 
to him, reading one or more words at a time, and requiring him to repeat 
them correctly after you. 



ANTERIOR POLIOMYELITIS 841 

Friedreich's Disease. — In a well-marked case, begin treatment with 
massage to improve the nutrition of the weakened and atrophied mus- 
cles and to help relax the spasm in the contracted muscles. In con- 
nection with the massage, passive exercise of the limbs is given and 
gradual and persistent extension is made upon the contractures, en- 
deavoring to gain a httle each day until the hmbs are fully extended; 
then increase from day to day the time during which the limb is held 
at full extension and abduction. The degree of motion in the joints 
is utihzed by giving active movements. In order that the muscles may 
become stronger, shght resistance is given to these movements, and 
greater attention paid to the strengthening of the weaker groups of 
muscles. When the muscles have moved the limbs as far as possible, 
the extension must be completed by stretching or by pressure. A child 
should be taught how to turn over, after pushing up his arms out of the 
way. When l}dng prone he should try to draw up his knees under his 
body, and when his arms become flexible enough and strong enough, 
he should raise up his body until he rests on his hands and knees; later 
he is required to raise himself until he is sitting upon his legs, which are 
flexed imderneath his thighs. Have patient raise his body from a 
reclining to a sitting posture, sviih legs extended. Let him sit in a 
chair which is low enough to permit him to place his feet upon the floor, 
but without any supporting arms. Let him rise from a sitting to a 
standing posture by drawing back his feet underneath him, and inchning 
his body sHghtly forward, then straightening up to a standing posture. 
Have him balance, upon standing, from a few seconds to several minutes, 
stretching his body up to its full height. Give foot-placings, then let 
him attempt a few steps, pausing after each step to strengthen up, 
balance, and ''make himself tall." From this point the treatment is 
the same as that of the ataxia of the cerebellar tj-pe, except that the 
massage and work for overcoming the contractures must be continued 
indefinitely, or the progress will be slower. 

ANTERIOR POLIOMYELITIS 

Exercises should include action of all the groups of muscles of the 
limbs. The exercise of the muscles that are normal, or but httle im- 
paired, stimulates the nutrition of the neighboring impaired muscles. 

With the patient in a reclining position the thighs may be flexed, 
extended, abducted, adducted, and circumducted against resistance 
when possible. The leg may be flexed and extended, and the foot may 
be flexed, extended, abducted, and circumducted. These movements 
may be passive at first; later, when possible, they may also be taken 
standing. Flexion and abduction of the foot and extension of the toes 
are results which will come last. 

A faint response is sometimes seen after friction over the superficial 
points of the nerves supplying these muscles, or when the hmb is im- 
mersed in hot water, and when this response is seen the movements 
should be completed passively. As the muscles show signs of returning 
functions, the movements are repeated frequently during the day, but 



842 THE PRACTICE OF PEDIATRICS 

always stopped when the responsive motion becomes weaker, in order 
that fatigue may be avoided. When possible, the hghtest resistance 
should be given, so that the power of the muscles may be better ascer- 
tained, and their work thus gradually increased by increasing the re- 
sistance. An added stimulus may be given by having the normal limb 
execute the movement with the paralyzed hmb. Occasionally, move- 
ment is secured in all but one toe. Where there is improvement in any 
way in the paralyzed limb the treatment should be continued, for cases 
have shown that muscles may respond to treatment even though there 
may be no faradic reaction for more than a year. 

When the patient is able to walk, walking and marching exer- 
cises should be taken up, such as walking on straight lines to and from 
certain objects, walking on the toes, walking with the arms sideways 
shoulder high, and with arms in a vertical position. The blocks, 
boards, and ladder that are used in treating ataxic patients, previously 
described, are of use here. The use of a trough or of a narrow ladder with 
sides 6 or 8 inches in width serves to help the patient overcome the out- 
ward throw of the paralyzed leg. Although the dimensions of the ladder 
are different, the walking exercises outlined in the treatment of ataxia may 
be followed in part. In walking, the patient should endeavor to keep the 
foot flexed as much as possible, touching the heel first in bringing down 
the foot. The following may also be given : walking on the heels for a 
short distance; jumping; chmbing a ladder, using hands and feet; running 
(but do not permit an outward throw of the paralyzed leg — it must 
advance straight forward); hanging from a bar, swinging both legs 
forward, sideways, and backward, keeping heels together, and with feet 
apart. A light basket-ball or foot-ball may be used for kicking. Have 
patient practise the drop-kick, and show you how hard he can kick. 

Exercises for the Arms. — Flexion, extension, abduction, adduction, 
and circumduction of the upper arm; flexion, extension, and rotation 
for the forearm and wrist, with and without resistance. Have patient 
close hand as tight as possible, showing how hard he can strike. Have 
him catch a basket-ball and practise throwing it into a high basket at 
different distances. Drop a tennis-ball into his hands to catch; also 
toss and bound it for him to catch. Have him throw a tennis-ball for 
height and distance. The tendency is to throw the ball downward. 
Some of the special finger movements used in the treatment of ataxia, 
such as approximating the tip of the thumb and the tips of the fingers, 
the button exercise, the work with the pencil, etc., may also be given. 

Passive Exercises. — ^Where there is any tendency to contracture 
in the groups of muscles not paralyzed, or in which the degree of paralysis 
is only slight, passive exercises should be given to secure a normal range 
of motion of the contracted groups either in leg or arm. This must be 
kept up throughout the treatment for the purpose of lessening or over- 
coming the tendency to deformity. Care should be used, however, in 
not carrying the passive motion beyond the normal range. 

Resistance applied to movements of contracted muscles serves to 
stretch them more than does the passive stretching. 



CONSTIPATION 843 

Massage. — Gentle, deep kneading, light clapping, and hacking 
friction over the superficial points of the nerves and general friction 
should be given to the entire Hmb. 

Light hacking, vibration, and deep kneading should be given to 
the spinal muscles. 

Fifteen minutes of massage should be given once or twice daily as 
long as the treatment is needed. 

CONSTIPATION 

In addition to the measures suggested in a previous section (page 
236) for the rehef of constipation, gymnastic exercises may be 
brought into use. 

These exercises are given with two objects in view : one, to strengthen 
the abdominal walls, which mechanically stimulate the intestine; the 
other, to stimulate the general circulation, which quickens the portal 
circulation and increases the activity of the fiver. 

The first five exercises are taken from a reclining position. 

1. The knees straight and feet extended. Raise both legs until 
they are at a right angle with the body. 

2. Knees straight. Raise heels about four inches above couch; 
separate them as widely as possible; bring them together, and lower 
to couch. 

3. Kjiees straight. Raise heels ten or fifteen inches above the 
couch. Draw up the knees as close to the chest as possible, without 
raising heels. Extend the legs without raising or lowering the feet. 
Lower legs to couch. 

4. Feet held, or secured by strap. Raise body to sitting position 
without use of hands. The hands may be placed upon the thighs, 
folded upon the chest, placed back of neck, or the arms may be extended 
beyond the head. Changing the position of arms in the order named 
increases the exertion. 

5. Feet held. Circle trunk sideways, forward, sideways, back- 
ward to the starting position, starting to right and left alternately. 
Arms position as in number four. 

6. Hang from bar or round of ladder. Execute No. 1. (The posi- 
tion of body changed, but the relation of legs to body same as in No. 1.) 

7. Hanging position. Execute No. 2. 

8. Hanging position. Execute No. 3. 

9. Hanging position. Heels together, swinging legs from waist, 
describe as large a circle as possible with the feet. 

Each of the above exercises may be followed by a deep-breathing 
exercise. 

In a weak patient, the detail of straight knees need not, at first, 
be insisted" upon. If necessary, the patient may be assisted, the weight 
of the legs or body being partly supported imtil the patient is strong 
enough to execute the movement alone. 

10. Sitting on chair or stool. Hands placed back of neck, twist 
body right and left against resistance. 



844 THE PRACTICE OF PEDIATRICS 

11. Sitting position. Hands back of neck, bend body right and 
left against resistance. 

Exercises for the General Circulation. — Taken from a standing 
position : 

1. Bend trunk forward, touch floor with fingers, keeping the knees 
straight. 

2. Take a long step forward, bend the forward knee; bend trunk 
forward; touch the floor with fingers. Raise trunk, step back to posi- 
tion. Alternate feet in stepping. 

3. Stand with feet two foot-lengths apart. Raise arms sideways 
to shoulder height. Bend right knee and bend trunk to right side, 
touching floor with right hand. Raise body. Same to left. 

4. '^ Chopping." Stand with feet separated, fingers interlaced. 
Bend body forward, swinging hands to floor between feet. Raise 
body, swinging hands up over right shoulder, at same time twisting 
to right. Swing to floor. Same to left. 

5. Hop, feet apart, then together, quickly. 

6. Run in place — ^. e., without advancing. 

(a) With front of thighs kept in same plane with front of body, 
heels striking buttocks in running. 

(h) With each step in running, raise the knees as high as possible 
in front of body. 

The running and hopping should be done quickly, and continued 
long enough to get the body thoroughly warm. 

Passive Exercises. — 1. Trunk-rolling. Patient in a sitting position, 
feet separated and fixed. Grasp him by the shoulders, and with a 
continuous movement bend the body to the right, forward, left, back 
to the starting position. After the movement has been given several 
times, reverse the direction. 

2. Thigh-rolling. Patient in a semi-reclining position. Grasp 
patient's foot with right hand, his leg just below the knee with left. 
Raise thigh and circumduct it, the knee describing as large a circle as 
possible. 

Exercises with Resistance. — 1. Reclining position. Flex and ex- 
tend thighs. 

2. Semi-reclining position, with knees drawn up. Abduct and 
adduct thighs. 

The prescription for treatment may be arranged in this order: 
active exercises, passive exercises, exercises with resistance, ending 
with some deep-breathing exercises. 

FLAT-FOOT 

Flat-foot is a condition in which the ligaments and muscles of the 
foot are abnormally weak, and in which the anteroposterior arch may 
be partially or wholly depressed and fiattened. 

The leg is rotated inward and the foot everted; the weight of the 
body falls on the inner side of the foot; the interior malleolus is prom- 
inent; the entire sole of the foot rests on the floor; and when the feet 



FLAT-FOOT 845 

are placed side b}^ side and the toes and heels touch, the natural concavity 
of the inner line of the foot is replaced by a convexity. The patient 
complains of pain or weakness, and the tissues of the sole are weak and 
flabby. 

There are different methods of examining the outlines of the sole 
of the foot : standing wdth the foot on a plate of glass so that the sole 
of the foot may be seen from beneath; smearing the sole with vaselin 
and standing on a piece of blotting-paper; smearing it with charcoal 
and standing on a piece of white paper, etc. 

The patient should have proper rest. He should frequently sit 
with feet elevated and avoid exhaustion. When standing, he should 
occasionally invert the feet, and, when walking, walk with the feet 
parallel, as the Indians do, and for short distances walk on the outer 
borders of the feet. 

The feet should be cared for each day, giving attention to the nails 
and to bathing. Apply hot and cold water alternately, and rub vigor- 
ously in order to stimulate the muscles and the circulation. 

The feet should be properly clothed; the stockings should be even, 
smooth, and loose, but should not heat the feet. The shoes should be 
broad enough to permit free use of the muscles of the feet; the toe of 
the shoe should point slightly inward, and the inner border may be 
raised; the heels should be low and broad. 

The general condition of the patient should be carefully considered, 
his general tonicity — for its impairment will affect the condition of 
the feet. Judgment should be used in the care and use of the feet in 
rheumatism, and during and shortly after convalescence where there 
is a general relaxation of muscles and ligaments. Malnutrition and 
obesity, if present, should receive attention while the feet are being 
treated. 

In severe cases, in the beginning, the patient should be kept entirely 
off his feet, and given only passive exercises, massage, and bathing. 

Exercises. — 1. Rechning or semi-reclining position. Extend foot 
against resistance. 

2. Rechning position. Adduct and invert foot against resistance. 

3. Reclining position. Circumduct foot inward, upward, and out- 
ward with resistance apphed to the inward and upward motion. 

4. Standing position. Rise on toes. 

5. Standing position. Rise on toes; turn heels outward; lower 
heels slowly to floor. 

Passive Exercises. — 1. With one hand hold heel firm, at the same 
time pressing on the astragalus with an outward, upward motion of 
the thumb, while the other hand adducts, inverts, and flexes the foot. 
This may be done under hot water if the deformity is marked. 

2. Extension of foot. 

3. Adduction of foot. 

Massage. — Deep kneading, vibration, and clapping may be given 
to the foot and to the muscles of the calf of the leg. 

A gauze pad may be placed under the arch, and held by adhesive 



846 THE PRACTICE OF PEDIATRICS 

plaster or a rubber bandage, until a well-fitted plate can be made, 
which should be used for support in the intervals between treatments, 
until the muscles and ligaments have gained sufficient strength to 
hold the arch in a normal position. 



XXII. DRUGS AND DRUG DOSAGE 

DRUGS FOR INTERNAL USE 



Drug. 



ACETANILID. 

Not advised in the treatment of chil- 
dren. 
Acid, Arsenious. See Arsenic. 
Acid, Benzoic. Benzoic acid; flowers of 
benzoin. 

Used in cystitis of alkaUne type 

Acid, Gallic. 

Bismuth subgallate. (Dermatol.) 

Used internally as an intestinal astrin- 
gent, also externally 

Acid, Hydrochloric, Dilute. (Corre- 
sponding to 31.9 per cent, of abso- 
lute HCl.) 
Used in chronic gastritis with atony 

of the stomach 

Acid, Lactic. 

Used in fermentative diarrheas. Given 
best well diluted with syrup and water 

and at two-hour intervals 

Acm, Phosphoric, Dilute. (Containing 
10 per cent, orthophosphoric acid.) 

Used as a stomachic 

Acid, Salicylic. 

Seldom used uncombined. 
Bismuth subsalicylate. 

Intestinal astringent and sedative .... 
Methyl salicylate. (Synthetic oil of winter- 
green.) 

Antirheumatic 

Oil of wintergreen. (Natural.) 

Antirheumatic 

Salol. (Phenyl sahcylate.) 

Intestinal antiseptic and antirheu- 
matic 

Sodium salicylate. 

Antirheumatic . . 

Aspirin. (Non-ofl&cial.) (Acetyl-saUcylic 
acid.) 
Antirheumatic — a substitute for so- 
dium sahcylate, being less irritating to 
the stomach. Best given in capsules, 
for it is decomposed by alkalis and by 

moisture 

Acid, Tannic. 

IJsed in the form of: 
Tannalhin. (Dried albuminate of tan- 
nin.) 
Used as an intestinal astringent 



Dose. 



6 Months. I 18 Months. 3 Years. 5 Years 



1 gr. 



3-5 gr. 



j-^ drop 



1-2 drops 

1 gr. 

1 drop 
1 drop 

1 gr. 



1 gr. 



1-2 gr. 



1-2 gr. 
5gr. 

1 drop 

1 drop 
2-3 drops 

1-2 gr. 

2-3 drops 
2-3 drops 

1-2 gr. 
1-2 gr. 



1-2 gr. 



1-2 gr. 



2gr. 
10 gr. 

2 drops 

2 drops 
5 drops 

2gr. 

3 drops 
3 drops 

2gr. 
2-3 gr. 

2-3 gr. 
2-3 gr. 



3-5 gr. 
10 gr. 

3-5 drops 

3-5 drops 
10 drops 

3-5 gr. 

3-5 drops 
3-5 drops 

3gr. 
3-5 gr. 

3-5 gr. 
3-5 gr. 



847 



848 



THE PRACTICE OF PEDIATRICS 



Dkug. 



Acid, Tannic (Continued). 
Tannigen. (Acetyl-tannin.) 

Used as an intestinal astringent 

Also by rectum: 1 per cent, solution of 
tannic acid in an enema, for dysentery or 
colitis. 
Acid, Tartaric. 

Seldom used except as one of its salts. 

Potassium hitartrate. (Cream of tartar.) 

Diuretic, refrigerant, and aperient. 

Used as an ingredient of diuretic drinks. 

To one pint of water to be drunk in 

twenty-four hours is added: 

Potassium and antimony tartrate. (Tar- 
tar emetic.) 
Used as an expectorant. Its action 
is too violent for use as an emetic. Best 
given alone or with ipecac in a tablet or 
in a mixture with a simple elixir. 

May cause severe gastro-enteritis in 

too large doses 

Potassium and sodium tartrate. (Ro- 
chelle salt.) 

Laxative 

Aconite. (Aconitum napellus.) (Root 
contains 0.5 per cent, aconitin.) 
Tincture of aconite root (10 per cent.). 

Used in a beginning fever as a circu- 
latory sedative and an analgesic 

Alcohol. (Ethyl alcohol, spirits of wine.) 
Best given as whisky or brandy for 
a general stimulant toward the end of 
an illness or as a last resort. 
Brandy. (Spiritus vini gallici, contain- 
ing 39-47 per cent, alcohol by weight.) 

Whisky. (Spiritus frumenti, contain- 
ing 44-50 per cent, alcohol by weight.) 

Sherry wine. (Vinum xerici, containing 
alcohol, 15-20 per cent., by weight.) 

Aloes. 

Not advised in the treatment of chil- 
dren. 
Alum. 

Not advised in the treatment of chil- 
dren. 
Ammonium. 

Ammonium hromid. See Bromin. 
Ammonium chlorid. (Sal ammoniac.) 
Stimulating expectorant; best given 

dissolved in half an ounce of water. 

Ammonium carbonate. (Sal volatile.) 

Stimulating expectorant; best given 
dissolved in half an ounce of water ....... 

Solution of ammonium acetate. (Liquor 
ammonii acetatis or spirits of Minder- 
erus.) 



Dose. 



1-2 gr. 



15 gr. 



I drop 



5-10 drops 



5-10 drops 



gr. 



■tgr. 



18 Months. 


3 Years. 


1-2 gr. 


2-3 gr. 


2 dr. 




rkgi-.- 


T*o gr. 


30 gr. 


1-2 dr. 


J drop 


1 drop 


10-20 
drops 


20-30 
drops 


10-20 
drops 


20-30 
drops 


30 drops 


45drops- 
Idr. 


l-h gr. 


Igr. 


Mgr. 


Igr. 



3-5 gr. 



4 dr. 



ih gr- 



3-4 dr. 



1-2 drops 



30-40 
drops 

30-40 
drops 

1-2 dr. 



1-2 gr. 
1-2 gr. 



DRUGS FOR INTERNAL USE 



849 



Drug. 



Ammonium (Continued). 

Stimulating expectorant; best given 
well diluted in carbonic water. 

Used also as a diuretic, antipyretic, and 

diaphoretic , . . 

Aromatic spirits of ammonia. (Spiri- 
tus ammonii aromaticus.) 

Used as a stimulating expectorant, 
volatile stimulant, carminative, and anti- 
spasmodic. Best given well diluted with 
water 



Dose. 



Months. 18 Months. 3 Years. 5 Years. 



3 drops 



gr. 



Antimony. 

Antimony and potassium tartrate. (Tar- 
tar emetic.) See under Acid, Tar- 
taric. 
Antipyrin. 

Analgesic and sedative in pertussis and 
laryngitis. 

Best given alone in powder form, or 

with sodium bromid in solution 

Antitoxin. See Serum, Antidiphtheric. 
Apomorphin. 

Not ad\4sed in the treatment of chil- 
dren. 
Arsenic. 

Arsenious acid. (Arsenic trioxid or white 

arsenic.) 

Used in anemia, malaria, and chorea. 

Administered either in solution (see 

Fowler's solution) or in tablets with other 

ingredients. 

In large doses it is an irritant poison, 
causing puffiness of the eyes and gastro- 
enteritis, both of which are signs of an 
overdose. 

Cannot be given with astringents, tinc- 
tures, or decoctions or with solutions of 



Antidotes are hydrated iron with, mag- 
nesia, egg-albumen, and emetics. 

Given three times a day 

Fowler's solution. (Liquor potassii ar- 
senitis.) 

Uses, action, and antidotes are the 
same as those of arsenious acid. 

Best given in water into which it is 
freshly dropped i | drop 

ASAFETIDA. 

Emulsion of asafetida. (Milk of as 
fetida.} 
Used chiefly as an ingredient of ene- 
mata, especially in excessive tympanites. 

To 8 ounces of diluent . . . .■ , 

AspiDiuM. (Male-fern.) 
Oleoresin of male-fern. 
Teniafuge. 

Best given in emulsion or in capsules . . . 
Aspirin. See under Acid, Salicylic. 



3-5 drops 



lio gr- 



Idr. 



5 drops 



2gr. 



gr. 



2 dr. 



5-10 
drops 



3gr. 



T70 gr. 



1 drop 2 drops ^ 2-5 drops 



1 dr. 



Idr. 



10-15 gr. 



Idr. 



20-30 gr. 



54 



850 



THE PRACTICE OF PEDIATRICS 



Drug. 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years, 



Atropin. See under Belladonna. 
Basham's Mixture. See under Iron. 
Belladonna. (From the leaves of the 
Atropa belladonna, containing 0.35 
per cent, of alkaloid.) 
Atropin. (Alkaloid of belladonna.) 
Respiratory stimulant, antihidrotic. 
Used as a stimulant, a mydriatic, and 

for the cure of enuresis 

Tincture of belladonna (10 per cent, 
leaves). 

Uses similar to those of atropin 

Belladonna leaves. (Asthma powder.) 
Used occasionally with the leaves of 
conium and stramonium, and potassium 
nitrate (saltpeter) to relieve attacks of 
asthma. To be burned in a metallic 
receptacle. 
Benzoic Acid. See Acid, Benzoic. 
BiCHLORiD OF Mercury. See under Mer- 
cury. 
Bismuth. 

Bismuth subcarbonate. 

Intestinal astringent and sedative 

Bismuth subgallate. (Dermatol.) 
Intestinal astringent and sedative. 

Used also externally 

Bismuth subnitrate. 

Intestinal astringent and sedative .... 
Bismuth subsalicylate. See under Acid, 
Salicylic. 
Blaud's Pill. See under Iron. 
Borax. (Sodium borate.) See under So- 
dium. 
Brandy. See under Alcohol. 
Bromin. 

Used only in the form of its salts. 
Ammonium bromid. 

Sedative. Used in laryngismus, per- 
tussis, asthmatic bronchitis, and sleep- 
lessness. 

Best given well diluted with water 

Potassium bromid. 

Used same as the ammonium salt, but 

it is more depressing 

Sodium bromid. 

Used same as the above. It is midway 
between the ammonium and the potas 

slum salts in its depressant action 

Strontium bromid. 

Used same as the above 

Brown Mixture. See under Licorice. 
Caffein. 

Caffein sodiosalicylas (50 per cent. 

caffein) 

Caffein sodiobenzoas 

Citrate of caffein (50 per cent, caffein). 
General stimulant and diuretic 



shgr. 



10 gr. 

3-5 gr. 
5-10 gr. 



1-3 gr. 
1-3 gr. 

1-3 gr. 
1-3 gr. 






-U gr. 



1 drop 



10 gr. 

5 gr. 
10 gr. 



2-4 gr. 
2-4 gr. 

2-4 gr. 
2-4 gr. 

Mgr. 
1-1 gr. 

i-1 gr. 



2*0 gr. 



1-2 drops 



^^0 gr. 



3-5 drops 



10 gr. 

5-10 gr. 
10-15 gr. 



3-5 gr. 
3-5 gr. 

3-5 gr. 
3-5 gr. 



1-U gr. 
l-U gr. 

1 gr. 



20 gr. 

10 gr. 
20 gr. 



5-8 gr. 
5-8 gr. 

5-8 gr. 
5-8 gr. 



11-2 gr. 
U-2 gr. 

1-2 gr. 



DRUGS FOR INTERNAL USE 



851 



Drug. 



Dose. 



Months. 1 18 Months. 3 Years. 5 Years, 



Calcium. 

Calcium chlorid. 

Of some benefit in hemophilia and pur- 
pura hsemorrhagica 

Calcium lactate 

Calcium sulphid. 

Antipustulant 

Prepared chalk. 

Antacid 

Compound chalk mixture. (Mistura cretae 
composita.) 

20 per cent, chalk powder, 40 per cent, 
cinnamon-water. 

Antacid. Every two hours 

Calomel. See under Mercury. 
Camphor. 

Powdered camphor. 

Used in coryza. Every two hours 

Spirits of camphor (10 per cent, in alcohol) . 

Stimulant, anodyne, carminative 



Water of camphor. (Aqua camphorse.) 
(Contains 0.8 per cent, of camphor.) 
Used as a vehicle. . 
Cantharides. 
Used best in: 
Tincture of cantharides (10 per cent.). 
Useful in cystitis and functional al- 

buminm'ia 

Capsicum. 

Used best in: 
Tincture of capsicurn (10 per cent.). 

Used as a carminative and stomachic. 
Best given well diluted in water 



Cardamom. 

Used best as : 
Tincture of cardamom. 

Used as a carminative 

Cascara Sagrada. (Bark of Rhamnus pur- 
shiana.) 
Extract of cascara sagrada. 

(Foiu" times the strength of the bark.) 

Tonic laxative 

Cascara Sagrada (Continued). 

Fluidextract of cascara sagrada. (Aro- 
matic.) (1 c.c. = l gm. bark.) 
The active principles are retained, but 
the bitter principles are ehminated. 
Tonic laxative 



Castor Oil. (Oleum ricini.) 

(Expressed from the seeds of Ricinus 
communis.) 

Bland oil and cathartic. 

Given usually for one dose 

Cerium Oxalate. 

Sedative in vomiting 

Chalk. See Calcium. 



i gr. 
5 gr. 

2gr. 



1 dr. 



3 drops 



drops 



15 drops 



1 dr. 
2gr. 



1 gr. 
10 gr. 



3gr. 

Idr. 

igr- 
5 drops 



1-2 gr. 
20 gr. 

2'o gr- 
5 gr. 



Udr. 



t gr- 

5-10 
drops 



2gr. 
20 gr. 

TO gr. 
5-8 gr. 



2 dr. 

igr. 
10 drops 



1 drop 



10 drops 



30-45 
drops 



2 dr. 
2-3 gr. 



|-§ drop 



2-3 
drops 



15 drops 



1-2 gr. 



Idr. 



3 dr. 
3gr. 



^ drop 



3-5 drops 



20 drops 



3-5 gr. 



1-2 dr. 



4 dr. 
3-5 gr. 



852* 



THE PRACTICE OF PEDIATRICS 



Drug. 



Chloral Hydrate. 

Sedative, hypnotic, and antispasmodic. 
Best given in some bland fluid by rec- 
tum 

Chloroform. 

Given internally as: 
Spirits of chloroform. (Chloric ether.) 
(6 per cent, chloroform.) 
Carminative, antispasmodic, and sed- 
ative 



Water of chloroform. (Aqua chloro- 
formi.) (0.5 per cent, chloroform.) 

Vehicle and carminative 

Cinchona. See under Quinin. 
CocAiN, or: 

Cocain Hydrochlorid. 

Local anesthetic by hypodermic in- 
jection. 

Used in 0.2 per cent, to 4 per cent, 
strength. But seldom used for local an- 
esthesia in children. Used by the mouth 

in obstinate vomiting 

CoDEiN. See Opium. 
Cod-liver Oil. (Oleum morrhuse.) 
Fixed oil from fresh cod's livers. 
Alterative and tonic. 
Given three times a day 



Corrosive Sublimate. See Corrosive Chlo- 

rid of Mercury. 
Cream of Tartar. See under Acid, Tar- 
taric. 
Creosote. (Beechwood creosote.) 

Tonic, alterative, and antitubercular 
Best given in an emulsion with cin- 
namon-water, three times a day after 
meals 



Creosotal. (Carbonate of creosote — 92 
per cent, creosote.) 
Is preferable to creosote because it has 
little odor, a more agreeable taste, and 
is better borne by the stomach 



Dose. 



Months. 18 Months. 3 Years. 5 Years, 



2-3 drops 



dram 



1 gr. 



3-5 drops 



Dermatol. (Bismuth subgallate.) See 

under Bismuth. 
Digitalis. (From the leaves of Digitalis 
purpurea.) 
Heart stimulant and tonic; also diu- 
retic. 

Best given by mouth in the form of the 
tincture and hypodermically either as 
the tincture or as digitaUn. 
Tincture of digitalis (10 per cent, leaves) . . 

Infusion of digitalis (66 gm. = l gm. 

leaves) 

DigitaUn (10 times strength of leaves). 



10-15 
drops 



^ drop 



i drop 



15-20 
drops 



2 drops 



2 drops 



h drop 



2¥or gr- 



1 drop 



2^ gr- 



Ugr. 



5-15 
drops 

2-3 dr. 



^V gr. 



20-30 
drops 



2-3 
drops 



2-3 
drops 



2gr. 



15-20 
drops 

4 dr. 



2V gr. 



3-5 drops 



3-5 drops 



1-2 

drops 

Mdr. 

ih gr. 



2-3 drops 

1-3 dr. 

T^o gr- 



DRUGS FOR INTERNAL USE 



853 



Drug. 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years. 



Diphtheria Antitoxin. See Serum, An- 

tidiphtheric. 
Dover's Powder. See under Opium. 
Epsom Salt. See under Magnesium. 
Ergot. (From the sclerotium of the Clavi- 
ceps pui'purea of rye.) 
Hemostatic, heart and circulatory 
stimulant. 
Fluidextract of ergot {1 c.c. = l gm. ergot) 

Eriodictyox. See Yerba Santa. 
Ether. 

Used internally as : 
Compound spirits of ether. (Hoffmann's 
anodyne, 32.5 per cent, ether.) 
Anodjme, carminative, antispasmodic, 
And stimulant. 

Best given well diluted wdth water 



2-3 di'ops j 5 drops 



5-8 
drops 



10-15 
drops 



2 drops '3-5 drops 



5 drops 



Spirits of nitrous ether. (Sweet spirit 
of niter, 4 per cent, ethyl nitrite.) 

Used as a diaphoretic, diuretic and car- 
minative. 

It is volatile and explosive and in- 
compatible -^-ith many drugs. Best given 
alone or in a simple ehxir 



2-3 drops 3-5 dropj 



5 drops 



See 



Fel Bovis. See Ox-gall. 

FerrujM. See Iron. 

Fowler's Solution. See Arsenic. 

Gallic Acid. See Acid, Gallic. 

Gentian. 

Extract of gentian. 

Stomachic and bitter tonic. 

Given three times a day 

Glauber's Salt. (Sodium sulphate.) 

under Sodium. 
Glonoin. See Nitroglycerin. 
Glycerin. 

Used chiefly as a demulcent base and 
a vehicle for other drugs. 
Glycyrrhiza. See Licorice. 
Hexamethylenamin. Official name for 

the proprietary urotropin, q. v. 
Hoffmann's Anodyne. See under Ether. 
Hydrargyrum. See Mercury. 
Hyoscyamus. 

Tincture of hyoscyamus. 
Sedative and antispasmodic. 

Ipecac 

Syrup of ipecac 

Iron. Given every two hours. 
Liquor ferri et ammonii acetatis. 

(Basham's mixture — solution of iron 
and ammonium acetate — 10 per cent. 

metallic iron) 

Ovoferrin. (Proprietary organic iron.) . , . 

Pyrophosphate of iron (10 per cent, ofi 
metallic iron) 



l-igr- 



|-1 drop 



5 drops 



.5-10 
drops 



5-10 
drops 



Mgr. 



T5 gr. 
-2 drops 



10 drops 



3 drops 3-5 drops 



I dr. 
15-20 
drops 



Idr.- 
20-30 
drops 



1-2 gr. j 2-3 gr. 



854 



THE PRACTICE OF PEDIATRICS 







Dose. 




Drug. 


6 Months. 


18 Months. 


3 Years. 


5 Years. 


Iron {Continued), 

Syrup of the iodid of iron (5 per cent, fer- 
rous iodid) 


3 drops 
1 drop 

15 drops 
10 gr. 

5-10 gr. 

5-10 gr. 
10-15 gr. 

Togr. 
ikgr. 


6 drops 
3 drops 

20 drops 
10-20 gr. 

20 gr. 

10-20 gr. 
20 gr. 

T^ gr. 
i gr. 

iSogr. 


10 drops 
5 drops 

2gr. 

30-40 
drops 

30 gr. 

30-40 
gr. 

2 oz. 

20-30 
gr. 

20-30 
gr. 

Igr. 

jh gr. 
igr. 

ToSr- 


20-30 


Tincture of the chlorid of iron. 

(35 per cent, of ferric chlorid and must 
be at least one year old.) 

Jalap. 

Powdered jalap. (Contains 8 per cent. 
resin.) 


drops 

10-15 
drops 


Hydragogue cathartic and diuretic 

Lactic Acid. See Acid, Lactic. 

LiCOKICE. 

Compound licorice mixture. (Brown mix- 
ture — 12 per cent, paregoric.) 
Sedative expectorant mixture. 
Given at two-hour intervals 


3gr. 
40 drops 


Compound licorice powder. 

Laxative. . .... 


-Idr. 
40 gr. — 


Magnesium. 

Magnesium carbonate. 

Antacid and laxative 


Idr. 
40 gr.- 


Magnesium citrate, solution of. (Liquor 
magnesii citratis.) 
Laxative. For one dose 


Idr. 
2-4 oz. 


Magnesium oxid. (Calcined magnesia.) 
Antacid and laxative 


30-40 


Magnesium sulphate. (Epsom salt.) 

Laxative. To be given every two hours 
and discontinued when the desired effect 
has been produced . . ■. 


gr. 
h-l dr. 


Male-fern. See Aspidium. 
Mentha Piperita. See Peppermint. 
Mentha Viridis. See Spearmint. 
Mercury. 

Mass of mercury. (Blue mass — 35 per 
cent, mercury.) 
Cathartic and antisyphihtic. 
Used once a day 


1-2 gr. 


Corrosive chlorid of mercury. (Bichlorid 
of mercury or corrosive subhmate.) 
Antisyphilitic. 
Given three times a day .... ... 


h gr. 


Mild chlorid of mercury. (Calomel.) 
Cathartic, cholagogue, antisyphilitic. 
At thirty-minute intervals 




At one-hour intervals 


Igr. 


Rarely necessary to give more than one 
grain for laxative effect. 
Red iodid of mercury. (Biniodid.) 

Antisyphihtic. 

Given three times a day 


T^TU gr. 







DRUGS FOR INTERNAL USE 



855 





Dose. 


Drug. 








1 




6 Months. 


18 Months. 


3 Years. 


5 Years. 


Mercury {Continued). 










Mercury with chalk. (Gray powder.) (38 










per cent, mercury.) 










Intestinal antiseptic, cholagogue, and 










antisyphilitic. 










At one-hour intervals — total 1 gr 


igr. 


igr. 






At one-hour intervals — total 2 gr 






h gr. 


^"gr. 


Methyl Salicylate. See under Acid, Sal- 










icylic. 










MiNDERERUs, SPIRITS OF. See under Am- 










monium. 










MoRPHiN. See under Opium. 










Myrrh. 










Tincture of myrrh (20 per cent.). 










Used as a mouth-wash diluted with 










water. 










Niter. See under Ether, Sweet Spirits of 










Niter. 










Nitroglycerin. (Glonoin, glyceryl tri- 










nitrate.) 










Vasodilator 


¥^0 gr- 


3Wgr- 


^h gr- 


Twgr. 


Spirits of glyceryl trinitrate, or spirits of 


glonoin, old U. S. P. (1 per cent, al- 










cohohc solution) 


I drop 


3 drop 


§ drop 


1 drop 


Nux Vomica. (From Strychnos nux-vom- 
ica.) 
Tincture of nux vomica (1 per cent, strych- 










nin). 










Stomachic and stimulant 


1 drop 


1 drop 


1-2 drops 


2-4 drops 


Strychnin. (Alkaloid of nux vomica.) 


General stimulant, well borne by chil- 










dren. 










Every two or three hours 


1 1 


TTogr. 


rJo- gr- 


iJo gr. 


Oleum Gaultherium. (Oil of winter- 


40 2 

gr. 


green.) See under Acid, Salicylic. 










Oleum Morrhu^. See Cod-liver Oil. 










Oleum Oliv^. See Olive Oil. 










Oleum Ricini. See Castor Oil. 










Olive Oil. 










Laxative and nutrient 


15 drops 


15-30 


30 


Idr. 






drops 


drops- 




Used at night by rectum for the cure 










of constipation 


1 oz. 


li OZ. 


2 oz. 


3 oz. 


Opium. 

Sedative, anodyne, hypnotic. 










Tincture of deodorized opium (10 per cent.) 










Used in 3- to 10-drop doses in enemata 










as a sedative for children under five years 










of age. 










Camphorated tincture of opium. (Par- 










egoric — 0.4 per cent, opiima.) 










Sedative and analgesic 


3-5 drops 


10 drops 


15-20 


20-30 


Powder of ipecac and opium. (Dover's 


drops 


drops 


powder — 10 per cent, each of ipecac 










and opium.) 










Sedative 


Mgr. 


|-|gr. 


l-Ugr. 


2-3 gr. 





856 



THE PRACTICE OF PEDIATRICS 





Dose. 


Drug. 












6 Months. 


18 Months. 


3 Years. 


5 Years. 


Opium {Continued). 










Morphin. (Alkaloid of opium.) 










Not well borne by children and best 










given hypodermatically 


T-^o gr. 


T^o gr- 


■50 gr- 


■io- gr. 


Codein. (Methylmorphin.) 










As sulphate or phosphate 




rn gr. 


To gr- 


igr. 


Heroin. (Diacetylmorphin.) 




A O^ 




8 &* . 


As hydrochlorid. 










Bronchial sedative 




T¥¥gr- 


"So gr- 


TTT gr. 


Orange-juice. (Citrus aurantium.) 






3 &'■ . 


Antiscorbutic 


ioz. 


"- 


•• 


1 oz. 


Ox-gall. (Fel bovis — fresh ox-bile.) 




Used as a laxative in enemata — 3^-1 










dr. to a pint of water. 










Paregoric . Camphorated tincture of opium. 










See under Opium. 










Pepo. See Pumpkin Seed. 










Peppermint. 










Aqua mentha piperitce — Peppermint water. 










(0.2 per cent, oil of peppermint.) 










Carminative, sedative, corrective, and 










vehicle 


Idr. 


1-2 dr. 


3 dr. 


4 dr. 


Pepsin. 




Powdered pepsin 


1 gr. 


1-2 gr. 


2-3 gr. 


3gr. 


Essence of pepsin 


20 drops 


30-40 


40 


Idr. 






drops 


drops- 
Idr. 




Phenacetin. ^ (Acetphenetidin.) 










Antipyretic and analgesic 


igr- 


1 gr- 


l|gr. 


2gr. 


Phosphoric Acid. See Acid, Phosphoric. 


z &^ 








Phosphorus. 










Oleum phosphoratum (1 per cent, in alm- 










ond oil). 










Alterative 


1 drop 


1 drop 


H 


2-4 drops 


Syrup of hypophosphites. 






drops 




(Calcium, 4.5 per cent.; sodium and po- 










tassium, each, 1.5 per cent.) . 


|dr. 


f dr. 


Idr. 


1-2 dr. 


PiLOCARPIN. 










Not advised in the treatment of chil- 










dren. 










Potassium. 










Potassium acetate. 










Diuretic, refrigerant, and alterative. . . . 


1-2 gr. 


2-3 gr. 


3gr. 


5gr. 


Potassium bicarbonate. 










Should not be given to children on ac- 










count of its disagreeable taste. 










Potassium bitartrate. (Cream of tartar.) 










See under Acid, Tartaric. 










Potassium bromid. See under Bromin. 










Potassium citrate. 










Diaphoretic and diuretic. 










Used in acute bronchitis 


^-Igr. 


1-2 gr. 


3gr. 


4gr. 


Potassium chlorate. 










Astringent and antisialogogue. 










Used in stomatitis of every type, in 










tonsillitis and angina 


h gr- 


Igr. 


2-3 gr. 


3gr. 


Potassium iodid. 


/ o 








Antispasmodic and antisyphilitic 


Igr. 


1-2 gr. 


2-3 gr. 


3gr. 



DRUGS FOR INTERNAL USB 



857 



Drug. 



Potassium (Continued). 

Potassium and sodium tartrate. (Ro- 
chelle salt.) See under Acid, Tar- 
taric. 
Peunus Virginiana. See Wild Cherry. 
Pumpkin Seed. Pepo. 

Teniafuge. Best given in an emul- 
sion; average dose, 1 dr. 
Quassia. 

Infusion of quassia. 
Vermifuge. 

An extemporaneous infusion is made 
by adding 1 or 2 ounces of quassia chips 
to a pint of water. This is injected high 
up into the bowel. 

Used particularly to destroy the Oxy- 
uris vermicularis. 
QuiNiN. (Alkaloid of cinchona.) 

Bisidphate of quinin 

Sulphate of quinin 

Tincture of cinchona 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years. 



1 gr. 
1 gr. 



All these are bitter tonics and anti- 
periodics. 
Rhamnus Purshiana. See Cascara Sa- 

grada. 
Rhubarb. 

Powdered rhubarb. 

Laxative 1-2 gr. 

Rhubarb (Continued). 

Aromatic syrup of rhubarb. 

Laxative and flavoring medimn j 1 dr, 

Mixture of rhubarb and soda. 

Corrective and laxative. 
I^. Pulveris rhei, 

Sodii bicarbonatis aa xlviij 

Syrupi rhei aromatici g j 

Aquae q. s. ad gij 

M. Sig. — One to three doses daily i dr. 

RocHELLE Salt. See under Acid, Tartaric. 
Saccharin. (Benzosulphinidum.) 

Substitute for sugar, but 200 times 
sweeter. 

For 8 ounces of food, 3^-1 grain is suffi- 
cient. 
Saccharose. See Sugar. 
Salicylic Acm. See Acid, Salicylic. 
Salol. See under Acid, Salicylic. 
Santonin. (Anhydrid of santoninic acid.) 
Vermifuge, for round-worms partic- 
ularly t gr. 

Senna. 

Cathartic. Best given as compound 
hcorice powder, of which it is an ingre- 
dient (q. v.). 
Serum Antidiphtheriticum. (Diphtheria 
antitoxin.) 
For immunization: 
2000 to 5000 units. 



1-2 gr. 

1-2 gr. 

5-10 

drops 



2-3 gr. 
2 dr. 



2 dr. 



1 gr. 



2-3 gr, 
2-3^. 

15 
drops 



3-4 gr. 
3 dr. 



3 dr. 



1-2 gr. 



3-4 gr. 

3-4 gr. 
20-30 
drops 



5gr. 
4 dr. 



4 dr. 



2gr. 



858 



THE PKAGTICE OF PEDIATRICS 



Drug. 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years. 



Serum Antidiphtheriticum {Continued) 
In faucial diphtheria: 

5000 to 10,000 units and repeat in eight 
hours if required. 
In laryngeal diphtheria: 

10,000 units and repeat in eight hours if 
required. 

The repetition of the doses of antitoxin 
is discontinued only when the case ceases 
to require the serum. 

The dosage is independent of the age 
of the patient. 
Sodium. 

Sodium benzoate. 

Antiseptic, antipyretic, and antirheu- 
matic. 

Used in cystitis with alkaline fermen- 
tation to acidify the urine, which it does 

by the liberation of hippuric acid 

Sodium bicarbonate. 

Antacid, antirheumatic 

Sodium borate. (Borax.) 

Antiseptic and astringent. 

Used as a gargle and mouth-wash in 
angina and stomatitis — 1 dr. to 8 oz. of 
water. 

Sodium bromid. See under Bromin. 
Sodium iodid. 

Uses and doses the same as those of 
potassium iodid {q. v.). 
Sodium phosphate. 

Laxative and cholagogue 

Sodium sulphate. (Glauber's salt.) 

Cathartic. 

Used in intestinal infection of inactive 
type 



Sodium salicylate. See under Acid, Sali- 
cylic. 
Spearmint. (Mentha viridis.) 

Water of spearmint. (Aqua menthae viri- 
dis — 0.2 per cent, oil of spearmint.) 
Carminative, sedative, corrective, and 

vehicle 

Strontium. 

Strontium bromid. See under Bromin. 
Strophanthus. 

Tincture of strophanthus (11 per cent, in 

New Pharmacopeia, or twice former 

strength). 

Cardiac tonic and diuretic. Preferred 

to digitalis in th© treatment of children 

because better borne 

Strychnin. See under Nux Vomica. 
Sugar. (Cane-sugar or saccharose.) 

Sweetening agent. May be substi- 
tuted for lactose in the adaptation of cow's 
milk for infant-feeding. 

1 level tablespoonful equals 3^ oz. 



1 gr. 
1-2 gr. 



1-2 gr. 

2gr. 



2gr. 
3gr. 



3gr. 
5 gr. 



5-10 gr. 



15-30 gr. 



10-15 gr. 



30-45 gr. 



15-20 gr. 



40 gr.- 
Idr. 



20-30 gr. 



Idr. 



Idr. 



2 dr. 



3 dr. 



4 dr. 



1 drop 



1-2 drops 



2 drops 



2-3 drops 



DRUGS FOR EXTERNAL USE 



859 



Drug. 



Dose. 



! 
Months. I 18 Months. ! 3 Years. 5 Years. 



Sugar of Milk. (Lactose.) 










Used as an excipient and in the adapta- 










tion of cow's milk for infant -feeding. 










1 level tablespoonful equals }4 oz. 










SULPHONAL. 










Not ad%'ised in the treatment of chil- 










dren. 










Sulphur. 










Precipitated sulphur, or milk of sulphur. 










Laxative and alterative. Given usu- 










ally in sjTups or other heavy vehicles .... 


5gr. 


5-10 gr. 


15-30 


Idr. 


Used also as a reducing agent in bis- 






gr. 




muth mixtures when the stools do not 










become dark colored • 


Igr. 


1 gr. j 1 gr. 

1 


Igr. 


Tan^^at,bin. See imder Add, Tannic. 


Tannigen. See under Add, Tannic. 










Tartar Emetic. See imder Add, Tar- 










taric. 










Tartaric Acid. See Add, Tartaric. 










Terebene. 










Stimulating expectorant and antisep- 










tic 




1 drop 1-2 
j drops 


2 drops 






Terpin Hydrate. 










Expectorant and antiseptic. 










Used in subacute and chronic bron- 










chitis 






Igr. 


Igr. 


Trional. 






Not advised in the treatment of chil- 










dren. 










Urotropin. (Trade name for hexamethy- 










lenamin.) 








Urinary antiseptic and sedative 


§gr. 


1 gr. 1-2 gr. 


2-5 gr. 


Whisky. See imder Alcohol. 










Wild Cherry. 










Syrup of wild cherry. (SjTupus pruni vir- 










giniani.) 










Bronchial sedative and vehicle. 










Contains hydrocyanic acid 


•• 


•• 


^dr. 


Idr. 







DRUGS FOR EXTERNAL USE 

Acm, Boric. 

Antiseptic of mild grade. 4 % is a saturated solution. 

LTsed both in solution and in ointments. 

In the form of scales it is most soluble and most convenient. 
Acid, Carbolic. See Phenol. 
Acid, Chromic. (Chromic Trioxid.) 

A very strong caustic and astringent, used as a substitute for Nitrate of Silver. 
Acm, Nitric (68 % pure acid). 

Used as a caustic. 
Acid, Salicylic. ^ 

Used in lotions or in ointments, 1% to 3%, for skin affections. 
Acid, Taistntic. 

Astringent. 

Used in 19o solution in dysentery; as an ingredient of suppositories for hem- 
orrhoids. See also Glycerite of Tannin under Glycerin. 



860 THE PRACTICE OF PEDIATRICS 

Adrenalin. (Trade name for the active principle of the Adrenal Gland.) 

Used in a solution in the strength of 1 part to 1000 of normal saUne solution 
or sterilized oil. 

^ Local hemostatic and astringent. It will render bloodless the field of opera- 
tion of the eye, nose, and throat, bub its use is often followed by hemorrhage. 
Aluminium Acetate, Solution of. 

Antiseptic dressing for celluhtis, abscesses, etc. 

1. I^ Aluminii sulphatis 533^ 

Acidi acetici 5 ^Yz 

Aquae 5 10 



2. I^ Calcii carbonatis § 1 



Aquae. . §23^ 

Add 1 to 2, stirring. 

Amylum. See Starch. 
Argentum. See Silver. 
Argyrol. See Silver. 
Aristol. (Thymol Di-iodid.) 

Mild antiseptic, used as a dusting-powder or in ointments. 
Balsam of Peru. 

A stimulating dressing for wounds and ulcers. 

In Castor Oil, one part of the Balsam to six of the oil. It makes a useful ap- 
plication for burns and wounds. 
Benzoin. 

Compound Tincture of Benzoin. 

Used as a bronchial sedative in steam inhalations, one-half ounce to two pints 
of water. 
BiCHLORiD OF Mercury. See under Mercury. 
Bismuth Subgallate. (Dermatol.) 

Used externally as a drying antiseptic powder, either pure or in combination. 
Also as an ingredient of ointments of 10% to 20% strength. 
BoRACic Acid. See Acid, Boric. 
Cacao-butter. (Oleum Theobromatis.) 

A fixed oil expressed from the seeds of the Theohroma Cacao. Melts at 30°- 
35° C. (86°-95°F.). 

Used as an emollient and as a base for suppositories. It may be used for nu- 
trient inunctions, but it is less effective than Goose Oil. 
Calamine. (Zinc Carbonate.) 

Used as an ingredient of soothing lotions in itching affections of the skin — ec- 
zema, urticaria, dermatitis venenata, etc. 
Calomel. See under Mercury. 
Cantharides. 

Vesicant. Used best in the form of Collodion of Cantharides, q. v. 
Carron Oil. (Linimentum Calcis.) 

Consists of equal parts of Lime-water and Linseed Oil. 
Used as a soothing application for burns and scalds. 
Chloroform. 

Locally a rubefacient and, when confined, a vesicant as well. A useful in- 
gredient of liniments. 

By inhalation, a general anesthetic. 
Chrysarobin. 

Used in 5% ointment for psoriasis and tinea tonsurans. 

COCAIN. 

Alkaloid obtained from several varieties of Coca. 

A local anesthetic when applied to wounds or mucous surfaces or when in- 
jected hypodermically. 

For local application, 3% to 10% solutions. 
For hypodermic use, 0.2% to 4% solutions. 
Cod-liver Oil. 

May be used locally as a nutrient inunction, but its odor is objectionable. 
Collodion. 

Solution of Pyroxylin in Alcohol and Ether. 
Collodion of Cantharides (60% Cantharides). An excellent bhstering agent. 
Collodion of Ichthyol (10%-20%). Used to cover the wound after aspirations 
or lumbar punctures, and in checking the spread of erysipelas. 



DRUGS FOR EXTERNAL USE 861 

Collodion of Iodoform (5%). Used in erysipelas. 

Collodion of Oil of Cade (l%-5%). Used in eczema. 

Collodion of Salicylic Acid (10%). Used in removing corns and calluses. 
Creosote. 

Used in inhalations as a pulmonary antiseptic. 
Dermatol. See Bismuth SubgaUate. 

EUCAIN. 

Beta-eucain. Local anesthetic with action and uses similar to those of Co- 
cain, but without its toxicity. Solutions can be steriUzed without injury by 
boihng. 

FORMALDEHYD. 

Antiseptic and deodorant. 

Used in solutions of from 0.5% to 2% strength, as an antiseptic. 
Used in the form of the gas for disinfecting, the gas being generated by heat, 
from solutions, or from the solid, Paraform. 
Glycerin. 

Used chiefly as a solvent or excipient. Very hygroscopic. It is the base of 

the Glycerites. 

Glycerite of Carbolic Add — 20% phenol in glycerin. An external antiseptic and 

antipruritic. 
Glycerite of Starch — 10%. A vehicle for skin preparations and for pills. 
Goose Oil. 

The oil tried from the goose. An excellent oil for nutrient inunctions. It is 
better than Ohve Oil or Cacao-butter, for, being an animal oil, it is more readily 
absorbed by the skin. It is semifluid, has a low melting-point, and does not be- 
come hard after having been rubbed in. 
Grindelia Robusta. 

The fluidextract, in the strength of one dram to a pint of water, is used as a 
wet dressing in dermatitis venenata. 

GUAIACOL. 

Combined with equal parts of Glycerin, it is used in acute joint affections, for 
its analgesic effect. 
Hamamelis. See Witch-hazel. 
Hydrargyrum. See Mercury. 
Hydrogen Peroxid. 

Antiseptic and deodorizer. Used in 10-volume, 3% solution to clean wounds, 
and to dissolve and destroy pus. 
Ichthyol. 

Used in 1% solution in intertrigo. 

Used in 5% to 50% solutions in skin diseases or in erysipelas. 

Used in 5% to 50% ointments in skin diseases or in erysipelas. 

Used suspended in oil in strength of 5% to 25% as a nasal spray. 

lODIN. 

Tincture of lodin (7%). 

Antiseptic and counterirritant. 

Used particularly in tinea tonsurans and tinea circinata. 
Iodoform. Formyl Tri-iodid. 
Antiseptic and alterative. 

Used in the form of a powder, an ointment, or on gauze in the strength of 5% 
to 10%,. 
Kaolin. 

Cataplasma Kaolini. 

A smooth, homogeneous mass, consisting of Kaolin, Boric Acid, Thymol, 
Methyl Salicylate, Oil of Peppermint, and Glycerin. 
Lanolin. 

Used as an ointment base. 
Lead and Opium Wash. 
Anodyne lotion. 

I^. Liquoris plumbi subacetatis §iv 

Tincturse opii § j 

Aquae §xvj 

Fiat mistura. 

Sig. — Use externally. 



862 THE PRACTICE OF PEDIATRICS 

Menthol. (Peppermint Camphor.) 

Sedative, analgesic, refrigerant, and antipruritic. 
Used in ointments, 1% to 5%. 
Used in oily solutions, 1% to 5%. 

Used triturated with equal parts of Camphor as an anodyne. 
Mebcury. 

Bichlorid of mercury. 

Antiseptic. Used in 1 : 1000 to 1 : 20,000 solutions. 
Calomel. 

A milder antiseptic than the foregoing. Used as a dusting-powder in eye af- 
fections and in the lesions of secondary syphihs. 
Mercury and ammonium chlorid. (White precipitate.) 

Used in ointments of 1% to 10% strength as an antiparasitic and antisyphil- 
itic. Of particular value in impetigo contagiosa, ringworm, etc. 
Yellow oxid of mercury. 

Antiseptic. Used in ointments of 0.5% to 10% strength in ophthalmia. 
Of value also in ringworm and syphiUtic eruptions. 
Mustard. 

Counterirritant . 

In the form of papers (chartce) for local pain or vomiting. 

In the form of powder: 

In pastes of a strength of 1 part of mustard to from 2 to 6 parts of flour. 
In baths — 1 tablespoonful to 6 gallons of water. 
In packs, in the same proportion. 
Oil of Cade, (Oil of Juniper Tar.) 

Used as an antiparasitic in skin diseases. 
In powders, 1% to 5% in a base of stearate of zinc. 
In ointments, 1% to 5%. 
In collodion, 1% to 5%. 
Oil of Turpentine. (Spirits of turpentine.) 
Rubefacient and counterirritant. 
Used as an ingredient of liniments. 

Used in the form of turpentine stupes for the reHef of abdominal distention. 
Flannel cloths are wrung out in hot water to each pint of which 10-20 drops of oil 
of turpentine have been added, and are then applied to the abdomen. 
Olive Oil. 

Used externally as a nutrient inunction. 
Petrolatum (Petroleum Jelly or "Vaselin")- 

Used as a base for ointments. 
Phenol. (Pharmacopeial name of Carbolic Acid.) 
Local anesthetic and antiseptic. 

Used as an antiseptic in solutions of the strength of 5% or less. 
Used as a caustic and local anesthetic in strength of 95%. 
Children are very susceptible to phenol poisoning. 
Pix Liquid A. See Tar. 
Potassium Permanganate. 

Antiseptic and disinfectant. 

Used in solutions in the strength of 1 : 4000 to 1 : 2000 on mucous surfaces, 
and in the strength of 1 : 1000 on ulcers and superficial wounds. 
Resorcin. 

Antiseptic in skin diseases, particularly in seborrheic eczema. 
Lotions, 1% to 5%. 
Ointments, 1% to 5%. 
Silver. 

Silver Nitrate. Antiseptic and astringent. Used in solutions of 1% to 50% 
strength. As a caustic, it is used in the soUd form. 
Argyrol. (Silver Vitellin — Proprietary.) 

A mild antiseptic, not approaching the nitrate in efficacy. Used in solutions 
of 5% to 50% strength or in ointments of 5% to 50% strength. 
Sodium Bicarbonate. 

Used in saturated solution as an antipruritic and as an analgesic in skin dis- 
eases and burns. 
Starch. 

Used as the base of drying-powders. 
Sulphur. 

In 5% to 25% ointments as a parasiticide, particularly in scabies. 



DEUGS FOR EXTERNAL USE 863 

Tab. (Fix Liquida.) 

Antiseptic. IJsed in skin diseases as the official ointment (50%) or in oint- 
ments with other ingredients. 
Zinc Oxid. 

Used as a 20% ointment in benzoinated lard, in skin diseases, such as eczema, 
needing a mild astringent. 

Used in dusting-powders in the strength of 5% to 10%. 

Official zinc ointment makes a good base for stronger antiseptics, such as tar 
and oil of cade. 



INDEX 



Abbe on removal of kidney sarcoma, 439 
Abdomen, tuberculosis of, 364 
Abdominal breathing, 813 

tonsil, 252 

tuberculosis, 694 
treatment, 695 
Abscess, acute retropharjTigeal, 275- 
277 

ischiorectal, 262 

mammary, in new-born, 155 

of liver, 264 

peritonsillar, 283 

pulmonary, 360 
Absence, congenital, of bile-ducts, 153 

of esophagus, 171 
Abt on diabetes mellitus, 735 
Acarus scabiei, 572 
Accoucheur hand in tetany, 494 
Acetonuria, 737 

treatment, 738 
Achondroplasia, 725-727 
Acidosis, 713 

cyclic vomiting with, 714, 715 

etiology, 713 

in gastro-enteric intoxication, 195 

in lobar pneumonia, 325 

patholog}^, 713 

symptoms, 714 

treatment, 715 
Aconite in acute diffuse nephritis, 447 
Adami and Nicholls on pathology of 
typhoid, 658 
on rachitis, 118 
Adams position in scoliosis, 822 
Adenitis, acute cervical, 415 

simple, glandular fever and, differ- 
entiation, 419 

axillary, 417 

effect of removal of tonsils and 
adenoids on, 301 

in influenza, 675 

in scarlet fever, 648 
treatment, 654 

inguind, 417 

persistent simple, 418 

retropharyngeal, 275 

spasm and, differentiation, 280 



Adenitis, suppurative, treatment, 417 

tuberculous, 420 
Adenocarcinoma of kidney, 439 
Adenoid curets, 299 
face, 295 

tissue in leukemia, 408 
Adenoids, 293 
absence of facial deformity in, 295 
age incidence, 294 

and tonsils, radical removal, adhe- 
sions after, 300 
benefits from, 300 
as cause of chronic rhinitis, 269, 270 

of cough, 272 
association with enlarged tonsils, 296 
diagnosis, 296 
drop jaw in, 295 
etiology, 293 
facial expression, 295 
method of examination in, 296 
mouth-breathing in, 294 
necessity'' for operative interference 

in, 297 
operation for permanent relief, 297 

for temporary relief, 296 
pathology, 293 
radical removal of, 298 
removal of, 299 
rhinitis in, 294 
symptoms, 294 
treatment, 296 
without facial deformity, 295 
Adenoma of brain, 502 

of kidney, 438 
Adenosarcoma of kidney, 439 
Adherent pericardium, 393 

pleura as cause of cough, 273 
Agglutinins, 797 
Agoraphobia, 498 
Air, cold, in acute illness, 134 
in lobar pneumonia, 328 
for nursing mother, 25 
fresh, for dehcate children, 126 
for new-born infant, 19 
for premature infant, 141 
in habitual loss of appetite, 80 
in whooping cough, 619 



55 



865 



866 



INDEX 



Airing of nursery, 37 
Albuminuria in scarlet fever, 648 

orthostatic, 452 
Alcohol, 782, 783 

in bronchopneumonia, 340 

in lobar pneumonia, 331 

in sepsis in new-born, 147 
Alessandrini on pellagra, 738 
Alkalis in milk adaptation, 63 
Allergy, food, 79 
Alpine scurvy, 738 
Amaurotic family idiocy, 507-509 
Amberg on eosinophilia in amebic 

dysentery, 399 
Ammonia, excessive excretion of, 100 
Ammonium salts, 782 
Amoss and Wollstein on serum treat- 
ment of cerebrospinal meningitis, 564 
Amphoric breathing, 307 
Amyotonia congenita, 153 
Amyotrophic lateral sclerosis, 526, 527 
Amyotrophies. 526 
Amyotrophy, muscular, 530 

progressive, 526, 530 

Landouzy-Dejerine type, 530 
of Erb's juvenile type, 530 
scapulohumeral type, 530 
Anaphylaxis, 708 

pollen, in hay-fever, 301 
Anatomy of stomach, 172 
Anderson and Goldberger on measles, 620 
Anemia, 402 

brickmaker's, 247 

functional heart murmur in, 373 

miner's, 247 

pernicious, 408 
blood in, 409 
lesions, 408 
symptoms, 409 

prognosis, 403 

pseudoleukemia of von Jaksch, 406 
treatment, 407 

secondary, blood transfusion in, 404 

symptoms, 403 

treatment, 404 
Anencephalus, 501 
Anesthetics, 750 
Angina gangraenosa, 626 

maligna, 626 

membranous non-diphtheric, in diph- 
theria, 647 

Vincent's, 285 
treatment, 285 



Angioma, 598. See also N(fvus. 
Angioneurotic edema, 570 
Angiosarcoma of brain, 502 
Ankylostoma duodenale, 250 
Antacids in milk adaptation, 63 
Antibodies, 797 
Antipyretic drugs as means of relieving 

fever, 746 
Antipyrin in whooping-cough, 618 
Antispasmodics in spasmodic croup, 

291 
Antitoxin syringe, 633 

tetanus, in tetanus neonatorum, 157 
treatment of diphtheria, 632 
dosage, 633 
late injection, 634 
means of injection, 633 
promptness, 633 
site of injection, 634 
urticaria after, 635 
Antrum disease, staphylococcus vac- 
cine in, 799 
Anus and rectum, prolapse of, 258 
treatment, 258 
fissure of, 260 
inflammation of, 260 
Aortic disease, treatment, 391 

regurgitation, heart murmur in, 372 
stenosis, murmur in, 372 
Apathy, mental, in cerebrospinal men- 
ingitis, 560 
Aphthous stomatitis, 163 
Appendicitis, 252 

acute, peritonitis and, differentiation, 
254 
pneumonia and, differentiation, 
254 
age incidence, 253 
chronic, 255 

exploratory incision in, 254 
interval operation in, 255 
intussusception and, differentiation, 

254 
leukocytosis in, 254, 398 
localized muscle rigidity in, 253 
periodic vomiting and, differentia- 
tion, 254 
pleurisy and, differentiation, 254 
prognosis, 254 
symptoms, 253 
treatment, 254 
Appetite, habitual loss of, 79-81 
in pyloric stenosis, 189 



INDEX 



867 



Archanzelsky on tuberculous menin- 
gitis, 556 
Aretaeus on diphtheria, 626 
Arms, exercise for, in anterior poho- 

myelitis, 842 
Arnold sterilizer, 75 
Arsenic in chorea, 522 
Arsenobenzol in acute hereditary 

syphihs, 685 
Arthritis deformans, 724 
treatment, 724 
diagnosis, 757 
gonorrheal, diagnosis, 757 
in scarlet fever, 648 
treatment, 656 
rheumatoid, 724 
treatment, 724 
Artificial feeding, 48 

cow's milk for, 49. See also Milk, 

cow's. 
factor of environment in, 48 
needs of patient in, 48 
nutritional errors in, 48 
successful, 49 
heat for premature infant, 140 
respiration in asphyxia neonatorum, 
150, 151 
Ascaris lumbricoides, 247 
Asclepiades on diphtheria, 626 
Asphyxia as cause of con\nilsions. 
484 
livida, 149 

treatment, 151 
neonatorum, 148 

delayed, 152 
• Dew's method of artificial respira- 
tion in, 150 
diagnosis, 149 
etiology. 148 
Laborde's method of artificial 

respiration in, 150 
pathology, 148 
prognosis, 149 
prophylaxis, 150 
Schultze's method of artificial 

respiration in, 150 
symptomatology, 148 
treatment, 150 
pallida, 149 

signs of recovers', 151 
Aspiration in secondary pleurisy, 351 
Asthma, climate in, 774 
eosinophilia in, 399 



.Isthmatic breathing, 307 
bronchitis, 310 
chest, 303 
Astraphobia, 498 
Ataxia, Friedreich's, 548-550 
hereditary, 548-550 

cerebellar, exercises for, 829-841 
spinal, exercises for, 829-841 
Atelectasis, 152 
AteHosis, 733 

Athetosis in cerebral paralysis, 517 
Athrepsia, 86. See also Marasmus. 
Atresia of urethra, 469 

of vagina, 469 
Atrophies, progressive muscular, 526 
Atrophy, infantile, 86. See also 
Marasmus. 
of liver, acute yellow, 264 
progressive spinal muscular, 526. See 
also Muscular atrophy, progressive 
spinal. 
Atropin in enuresis, 434 
Attendants in acute illness, 134 
Aura of epilepsy, 532 
Auscultation, 304 
Austin on icterus neonatorum, 144 
Autoserum treatment of chorea, 523 
Axillary adenitis, 417 

Bab COCK and Russell on proteid change 

in centrifugal cream, 74 
Babcock milk test, 54 
Babinski's phenomenon in cerebrospinal 

meningitis, 561 
Baby, blue, 386 

scales, 41 
Bacillus, Bordet and Gengou, 614 
coli communis in cystitis, 457 

injections of, in cystitis and pye- 
Utis, 801 
dysenteriae, 221 
influenzae, 670 
Klebs-Loffler, infection by, as cause 

of chronic rhinitis, 269 
of diphtheria, 627 

persistent nasal infection with, 637 
of typhoid fever, 657 
tetanus, 156 

typhoid fever, dead, inoculation of, 800 
Bacteria as etiologic factor in hemor- 
rhagic diseases of new-born, 158 
harmful, in cow's milk, 50 
harmless, in cow's milk, 50 



868 



INDEX 



Bacteria, suspension of, 798 
Bactericidins, 797 
Balanitis, 459 

Barley jelly, formula for, 70 
Barley-water, dextrinized, formula for, 
71 

formulas for, 70 
Barlow on scurvy, 112 
Barthez and Rilliet on congenital 

laryngeal stridor, 491 
Basch on extirpation of thymus gland, 
424 

on percussion of thymus gland, 427 
Basin bath for fever, 780 
Baskets for early exercises, 44 
Bassett and Duval on acute ileocolitis, 

221 
Bath, 778 

as means of relieving fever, 746 

basin, for fever, 780 

bran, 780 

brine, 780 

cold sponge, in bronchopneumonia, 
341 

compressed--air, in emphysema, 829 

for comfort in hot weather, 780 

for delicate children, 126 

for new-born infant, 20 

for sick child, 781 

hot, 781 

mustard, 780 

soda, 780 

starch, 780 

thermometer, 779 

tub-, for fever, 779 
Bauchwitz on blood-pressure, 401 
Beach on cretinism, 728 
Bed, position in, diagnostic value, 131 
Bed-sores, 597 
Bed-wetting, 432-434 
Beef broth, formula for, 70 

foods, proprietary, 73 

scraped, formula for, 70 

tape-worm, 249 
Beef -juice, formula for, 70 
Behring on diphtheria, 626 
Belladonna in enuresis, 434 
Beriberi, 740 

atrophic, 741 

dry, 741 

wet, 741 
Bernhard on heliotherapy, 366 
Bernhardt on scarlet fever, 643 



Bernheim on pyloric stenosis, 187 
Bezold on deafness in scarlet fever, 655 
Bichlorid of mercury, 782 
Biedert on whooping-cough, 616 
Bier's hyperemia in persistent simple 

adenitis, 418 
Biggs on septic sore throat, 286 
Bile-ducts, congenital absence, 153 
Billings on benzol in leukemia, 408 
Binswanger on epilepsy, 531 
Birch-Hirschfeld on icterus neonatorum, 

143 
Birth form of cerebral paralysis, 513 
Birth-mark, 598. See also Nckvus. 
Bismuth meal in ptoses and dilatation 
of stomach in older children, 177 

subnitrate in acute ileocolitis, 224 
Blackader on intestinal cysts and diver- 
ticula, 246 
Bladder, diseases of, 457 

exstrophy of, 458 

stone in, 458 
Blanchard on hypodermoclysis, 797 
Bleeder's disease, 411-413 
Blood, 394 

changes in hemophilia, 412 

coagulation time of, 402 

direct injection of, 787 

diseases of, 394 

findings in acute poliomyelitis, 536 

in infections by intestinal parasites, 
247 

in new-born, 394 
specific gravity, 394 

in pernicious anemia, 409 

in stools, 47 

in urine, 436 

transfusion, 786 
indications for, 786 
in secondary anemia, 404 
prevention of hemolysis in, 786 

vomiting of, 182 
Blood-cells, red, 394 
Blood-pressure in children, 401 
Blood-vessels in tardy hereditary syph- 
ilis, 686 
Blue baby, 386 
Blumenreich on percussion of thymus 

gland, 427 
Blundell on blood transfusion, 786 
Board, window-, 138 
Boils, 573 
Bone-marrow in leukemia, 408 



INDEX 



869 



Bones, changes in, in rachitis, 118, 119 

diseases of, diagnosis, 757 

in tardy hereditary syphiHs, 687, 688 

turbinated, hypertrophy of, as cause 
of chronic rhinitis, 269 
Bordet and Gengou bacillus, 614 
Bothriocephalus latus, 249 
Bottle, nursing-, 47 

nipple for, 47, 48 
Bouchut on icterus neonatorum, 143 
Bovaird and Nicoll on weight of thy- 
mus, 423 
Bovine tuberculosis, 691 
Bowditch on average weight of house- 
clothing, 40 
of new-born infant, 40 
Bowels, 136 

evacuation of, defective, 237 
Bowles stethoscope, 309 
Brace to prevent masturbation, 481 
Brain, cysts of, 502 

malformations of, 499 
individual lobes of, 501 

sepsis of, in new-born, 147 

tuberculosis of, 364 

tumors, 502 

tuberculous, 502 

wet-, in gastro-enteric intoxication, 
195 
Bran bath, 780 
Breast milk, analysis, 55 

of mother, 34 

pigeon-, 302 
Breast-fed infant, rachitis in, 116 

stools of, 46 
Breast-feeding, substitute, 48. See also 

Artificial feeding. 
Breast-milk, 31 

analyses of, 32 

conditions producing unfavorable 
effect on, 30 

examination of, 32 

proteids of, 32 
Breast-pump, English, 35 
Breasts, caking of, treatment, 35, 36 

care of, during weaning, 30 

inflammation of, in new-born, 155 
in young girls, 422 
Breath in cyclic vomiting, 716 
Breathing, 780. See also Respiration. 

abdominal, 813 

amphoric, 307 

asthmatic, 307 



Breathing, bronchial, 306 

distant, 305 

of moderate intensity, 305 

very loud, 305 
bronchovesicular, 307 
cavernous, 307 
deep, in emphysema, 828 
diminished, 306 
emphysematous, 307 
exaggerated, 306 
exercises, 814 

for older children, 815 

for younger children, 815 
in exercise, 806 
mouth-, in adenoids, 294 
thoracic, 813 
vesicular, 304, 305 

distant, 305 

exaggerated, 305 
weakened, 306 
Breck feeder, 141 
Bretonneau on diphtheria, 626 
Brickrnaker's anemia, 247 
Brine bath, 780 
Bromids in epilepsy, 534 
Bronchial breathing, 306 

distant, 305 

of moderate intensity, 305 

very loud, 305 
Bronchiectasis, 344 
Bronchitis, 310 

acute, bronchopneumonia and, dif- 
ferentiation, 336 

spasmodic, 316-320 
asthmatic, 310 
auscultation in, 311 
bacteriology, 310 
capillary, 316 
chronic, 310 

diagnosis, 311 

treatment, 314 
cough in, 311 
counterirritation in, 312 
diagnosis, 311 

differential, 314 
diet in, 312 
drugs in, 313 
duration, 311 
fever in, 310 
in influenza, 674 
mustard bath in, 313 
pathology, 310 
percussion in, 311 



870 



INDEX 



Bronchitis, physical signs, 311 
predisposing causes, 310 
primary, 310 

pulmonary tuberculosis and, differ- 
entiation, 314 
recurrent, 314 

bathing in, 316 

depending on rheumatic state, 712 

diet in, 315 

drugs in, 315 

treatment, 315 
secondary, 310 

diagnosis, 311 
simple, 310 

spasmodic, from direct irritation, 318 
steam inhalations in, 312 
symptoms, 310 
treatment, 311 
types, 310 
Bronchopneumonia, 332 
active types, 335 
acute bronchitis and, differentiation, 

336 
age incidence in, 333 
alcohol in, 340 
as cause of convulsions, 484 
auscultation in, 333 
baths in, 341 
bowels in, 337 

caffein sodiosalicylate in, 340 
cold sponging in, 341 
complications, 336 
counterirritants in, 338 
diagnosis, differential, 336 
diet in, 337 
drugs in, 339 
duration, 334 
etiology, 332 
fever in, treatment, 341 
following other diseases, 336 
heart stimulants in, 340 
hypodermic medication in, 340 
in influenza, 674 
in measles, 621 
in scarlet fever, 648 
lobar pneumonia and, differentiation, 

336 
mustard baths in, 339 

plaster in, 338 
nitroglycerin in, 340 
oxygen in, 342 
palpation in, 334 
pathology, 333 



Bronchopneumonia, percussion in, 334 

physical signs, 333 

prognosis, 336 

pyrexia in, treatment, 341 

rales in, 333 

respiratory murmur in, 333 

sick-room in, 337 

special types, 334 

steam inhalations in, 338 

strophanthus in, 340 

strychnin in, 340 

symptoms, 334 

treatment, 337 

turpentine in, 338 
Bronchovesicular breathing, 307 
Brophy's operation for cleft palate, 169 
Broths, animal, in gastro-enteric in- 
toxication, 199 

beef, formula for, 70 

mutton, formula for, 70 
Brown and Holt on salvarsan in syphilis, 

684 
Brown on tuberculin skin reactions in 

infancy, 703 
Bruck on Wassermann test for syphilis, 

704 
Buckley on tinea tonsurans, 578 
Buhl and von Hecl^er on hemorrhagic 

diseases of new-born, 157, 159 
Buhl's disease, 157 
Bulan on siphon drainage in empyema, 

356 
Bulb, Hess, in pyloric stenosis, 189 
Bulbar paralysis, progressive, 527 
Bulkley on psoriasis, 597 
Bullock on hemophiha, 411 
Butter on whooping-cough, 614 
Butyric-acid test for syphilis, 705 
Buxton on measles, 619 

Cabot on bronchial breathing, 306 
on characteristics of respiration, 305 
on leukocytosis in peritonitis, 398 
on pseudoleukemic anemia, 406 

Caffein sodiosalicylate in broncho- 
pneumonia, 340 
in lobar pneumonia, 330 

Caking of breast, treatment, 35, 36 

Calculus, vesical, 458 

Calmette on tuberculosis, 693 

tuberculin test for tuberculosis, 703 

Calomel fumigations in spasmodic 
croup, 290 



INDEX 



871 



Calorimetric standard, 66 

Cancrum oris, 166 

Cannon on gastric digestion, 173 

Capacity of stomach, 172 

Capillary bronchitis, 316 

Caput succedaneum, cephalhematoma 

and, differentiation, 143 
Carbon incapacity as cause of eczema, 

585 
Carcinoma, 751 

of brain, 502 
Cardiorespiratory heart murmur, 373 
Care of teeth, 169 
Caries, tuberculosis of cervical vertebra, 

278 
Carpenter and Gittings on coagulation 

time of blood, 402 
Can on tuberculosis, 694 
Carrel on blood transfusion, 786 
Carriers, diphtheria, 627 
Carstanjen on blood in new-born, 394 

on transitional cells, 395 
Carswell on pemphigus neonatorum, 

580 
Casein of cow's milk, 49 
Castor oil, 782 
Catarrh, nasal, 269 
Catarrhal jaundice, 265 

laryngitis, acute, 287. See also 
Spasmodic croup. 

pneumonia, 332. See also Broncho- 
pneumonia. 

proctitis, 261 

stomatitis, 163 
Catheter feeding in pyloric stenosis, 193 
Cautley on cerebral paralysis, 514 

on polycythemia, 401 

on pseudoleukemic anemia, 406 
Cavernous breathing, 307 
Cazal on pellagra, 738 
Cecil on diabetes mellitus, 735 
Cells, transitional, 395 
Centrifugal cream, 74 
Cephalhematoma, 142 
Cephalogie epidemique, 557 
Cereal decoctions in gastro-enteric in- 
toxication, 200 

gruels, 66 

beginning feeding of, 67 
for milk adaptation, 64 
in gastro-enteric diseases, 67 
in infectious diseases, 67 
Cerebral palsies, 513 



Cerebrospinal fluid in anterior polio- 
myelitis, 536 
in cerebrospinal meningitis, 558 
meningitis, 557 
age incidence, 559 
Babinski's phenomenon in, 561 
bacteriology^, 557 
bowels in, 560 
cerebrospinal fluid in, 558 
complications, 562 
convulsions in, 560 
diagnosis, 561 

differential, 562 
duration, 562 
ears in, 560 
emaciation in, 562 
eyes in, 560, 562 
Flexner's serum in, 563-565 
fontanel in, 560 
fulminating cases, 559 
heart action in, 560, 562 
Kernig's sign in, 561 
mental apathy in, 560 
muscle rigidity in, 560 
patellar reflex in, 562 
pathology, 558 
position of patient in, 560 
respiration in, 560, 562 
serum treatment, 563-565 
symptoms, 559 

in fulminating cases, 559 
in recover}" cases, 561 
tache cerebrale in, 561 
temperature in, 560, 562 
transmission, 558 
treatment, 562 
vaccine treatment, 565 
Certified milk, 50. See also Milk, 

certified. 
Cervical lymph-nodes, tuberculosis of, 
420 
vertebra, tuberculous caries of, 278 
Chaillon on diphtheria, 626 
Chair, INIosher's kindergarten, 808 
Chapin dipper, 57 

on diet in malnutrition, 93 
on infant feeding, 51 
Charcot-Marie-Tooth t3^pe of progres- 
sive spinal muscular atrophy, 527 
Charcot's disease, 526 
Cheadle on scurvy. 111 
Chemical agents as etiologic factor in 
hemorrhagic diseases of new-born, 159 



872 



INDEX 



Cherry red spot in amaurotic family 

idiocy, 509 
Chest, asthmatic, 303 

auscultation of, 304 

contracted, 302 

defective expansion of, 303 

depressed, 302 

diseases of, 302 

distended, 303 

examination of, 302 

fixed, 303 

flatness of, 304 
exercise for, 839 

funnel, 302 

inspection of, 302 

palpation of, 303 

percussion of, 303 

rachitic, 302 
Chicken broth, formula for, 70 
Chicken-pox, 609-611 
Child, individual, treatment and care 
of, 139 

necessity of method in management, 
139 
Chine-cough, 614 
Chink cough, 614 

Chlorate of potash in stomatitis, 166 
Chloroform as anesthetic, 750, 751 

in convulsions, 486 
Chlorosis, 405 

Egyptian, 247 
Cholera infantum, 194. See also Gastro- 
enteric intoxication. 
Cholesteatoma of brain, 502 
Chondritis, fetal, 725 
Chondrodystrophia, 725-727 
Chondromalacia, 725 
Chorea, 518 

anglorum, 518 

antirheumatic treatment, 521 

arsenic in, 522 

autoserum treatment, 523 

chronic adult, 518 
progressive, 518 

congenital, 518 

diagnosis, 520 

drugs in, 521 

duration, 520 

electric, 518 

entertainment in, 521 

etiology, 518 

Fowler's solution in, 522 

gravidarum, 518 



Chorea, habit, 520 

spasm and, differentiation, 520 

major, 518 

minor, 518 

posthemiplegic, 518 

prognosis, 520 

recurrence, 520 

rheumatism and, relation, 519 

salicylate of soda in, 521 

school in, 521 

senile, 518 

supplementary treatment, 523 

symptoms, 519 

treatment, 521 

vulgaris, 518 
Choreic insanity, 518 
Churchill on lymphatic leukemia, 407 

on pneumococcus, 321 
Chvostek's sign in spasmophilia, 490 

in tetany, 495 
Circumcision, 461 

in phimosis, 460 
Cirrhosis of liver, 264 
Clark and Flexner on acute poliomye- 
litis, 537 
Clark on pyloric stenosis, 187 
Claw-hand in progressive spinal mus- 
cular atrophy, 527 
Cleft palate, 168 

Climate, change of, in habitual loss of 
appetite, 81 
in influenza, 677 

for delicate children, 127 

in asthma, 474 

in digestive disorders, 774 

in influenza, 773 

in malnutrition, 774 

in nephritis, 774 

in pneumonia, 773 

in pulmonary tuberculosis, 364 

in tetany, 497 

in tuberculosis, 774 

in whooping cough, 773 

influence of, in acute ileocolitis, 226 

therapeutic value, 773 
Clothing, effect of, oh posture, 807 

for deUcate children, 128 

for exercise, 803 

in acute illness, 134 

in eczema, 589 

in lobar pneumonia, 328 

in scarlet fever, 651 

in summer, 763 



INDEX 



873 



Clubbed fingers in congenital heart 

disease, 387, 388 
Coagulation time of blood, 402 
Codein in whooping cough, 618 
Cod-liver oil in rachitis, 121 
Coin test in pneumothorax, 346 
Coit on milk commission, 51 
Cold air in acute illness, 134 
in lobar pneumonia, 328 

as a therapeutic agent, 785 

compresses in spasmodic croup, 
290 

douche, 779 

in head, 267 

sponging in fever, 776 
Cole on enlarged thymus, 427 
Colic, 214-216 

counterirritants in, 776 
CoHtis in influenza, 674 

mucous, 229 
Colon flushing, 795 
technic, 796 

idiopathic dilatation of, 230 

irrigation, 793 

in acute enteric intoxication, 203 
in acute ileocolitis, 225 
in chronic ileocolitis, 229 
technic, 794 
Colonic feeding, 83 
Colony management in epilepsy, 534 
Comby on blood-pressure in contagious 
diseases, 402 

on cyclic vomiting in chronic appen- 
dicitis, 255 

on pseudoleukemic anemia, 406 
Complement-fixation test for syphiHs, 

705 
Compressed-air bath in emphysema, 

829 
Compresses, cold, in spasmodic croup, 

290 
Concepts, imperative, 498 
Condensed milk in malnutrition, 95 

sweetened, in marasmus, 91 
Congenital syphilis, 678, 684. See also 

Syphilis, acute hereditary. 
Congenitally weak infant, 140 
Congestion stage in lobar pneumonia, 

321 
Consanguinity, 744 

Consciousness, beginning of, in new- 
born infant, 43 
Constipated stools, hard, 46 



Constipation, 236 
exercise in, 843 
in bottle-fed, 239-241 
in chronic ileocohtis, treatment, 229 
in mechanical intestinal disturbances, 

treatment, 213 
in mother in maternal nursing, treat- 
ment, 25 
in mucous cohtis, treatment, 230 
in nurshngs, 238 
in older children, 241 
diet in, 242 

after fifth year, 243 
after second year, 242 
drugs in, 244 
etiology, 241 

from mechanical obstruction, 241 
local causes, 241 

measures in, 243 
regular habits in, 241 
in pyloric stenoses, 188 
in tardy malnutrition, 102 
obstinate, after acute ileocolitis, 
treatment, 227 
treatment, 244 
Contagious diseases, 608 

precautions for physician in, 609 
Contracted chest, 302 
Convalescence in acute endocarditis, 
383 
in erysipelas, 584 
in myocarditis, 385 
Convulsions, 483 

asphyxia as cause, 484 

bronchopneumonia as cause, 484 

chloroform in, 486 

dentition, 485 

diet in, 486 

enlargement of thymus gland as 

cause, 484 
enterocohtis as cause, 484 
etiology, 483 

gastro-intestinal causes, 483 
heredity as cause, 484 
hypodermic medication in, 486 
in acute diffuse nephritis, 444 
in cerebrospinal meningitis, 560 
in dentition, 170 
intestinal parasites as cause, 484 
inward, 485 
manifestations, 485 
of toxic origin, 484 
phimosis as cause, 484 



874 



INDEX 



Convulsions, prognosis, 485 

rachitis as cause, 483 

repetition, 485 

sedatives in, 486 

tetany as cause, 485 

treatment, 486 

uremic, 484 
Cooke and Hamilton on gonococcus 

vaccine, 800 
Cool pack, 777 

Cord, umbilical, care of stump, 41 
Corn-bread disease, 738 
Corpuscles, white, normal, 394 
Corwin on starch digestion, 68 
Coryza, 267 
Cough, 272 

adenoids as cause, 272 

chink, 614 

habit, 272 

in bronchitis, 311 

in influenza, 672 

in measles, 620 
treatment, 623 

king's, 614 

nervous, 272 

persistent, 272 

pertussis as cause, 273 

stomach, 272 

teething, 272 

tracheal, 273 

tuberculosis as cause, 273 

types, 272 
Counterirritants, 775 
Cow's milk. See also Milk, cow's. 
Cracked nipples, 34 

Craig on complement-fixation test in 
syphilis, 705 

on malaria, 667 
Craniectomy in microcephalus, 500 
Craniotabes in rachitis, 118, 119 
Cray on starch digestion in infant, 68 
Cream, 73 

and milk mixtures, 56-58 

centrifugal, 74 

gravity, 56, 73 
Creosote, 782 
Cretinism, 727 

acquired, 730 

rachitis and, differentiation, 120 

thyroid treatment, 731-733 
Cretinoid idiocy, 727. See also Cretin- 
ism. 
Crile on blood transfusion, 786 



Crocker on tinea tonsurans, 576 
Croup, spasmodic, 287, 487. See also 

Spasmodic croup. 
Cruveilhier on ulcers in stomach in 

melena, 158 
Crying, 44 

Cummins on trichiniasis, 251 
Curds in stools, 47 
Curets, adenoid, 299 
Curling on cretinism, 728 
Curvature of spine, lateral, 820. See 

also Scoliosis. 
Cushing on dyspituitarism, 428 
Cutaneous sensibility in new-born in- 
fant, 42 
tuberculin test in tuberculosis, 701 
Cyclic diarrhea, 719 
vomiting, 715 
breath in, 716 
diagnosis, differential, 717 
drugs in, 717 
etiology, 715 
prognosis, 717 
sodium bicarbonate in, 718 
symptoms, 716 
treatment in interval, 717 

of acute attack, 718 
with acidosis, 714, 715 
Cyclops, 501 
Cystitis, 457 

injection of Bacillus coli in, 801 
Cysts, intestinal, 246 
of brain, 502 

parasitic, 502 
of kidney, 441 
Czerny and Keller on excessive am- 
monia excretion, 100 
on tetany, 493 

Dactylitis, 699 

differentiation of types, 701 

syphilitica, 699 

tuberculosa, 699 
Dana on congenital ataxias, 830 

on porencephalus, 501 
Dance, St. Vitus', 518. See also Chorea. 
Danielson and Mann on cerebrospinal 

meningitis, 557 
Dare on hemoglobin in anemia, 404 
Davis on influenza, 671 

on whooping-cough, 615 
Days to go out-of-doors, 762 
Day-terrors, 470 



INDEX 



875 



Deaderick and Thompson on pellagra, 

740 
Deafness, 600 
Decubitus, 597 
Deficiency, mental, 503. See also 

Mental deficiency. 
Deformities in rachitis, treatment, 122 
Deformity following untreated cases of 

empyema, 356 
Dejerine on epilepsy, 531 
Delayed asphyxia, 152 
DeUcate child, 122 
bathing, 126 
care of, 123-129 
climate in care of, 127 
clothing for, 128 
diet for, 124 

after first year, 125 
effect of removal of tonsils and 

adenoids on, 301 
entertainment, 128 
exercise, 128 
fresh air, 126 
mid-day nap, 128 
nursery, 127 
sleep for, 127 
treatment, 123 
weighing, 124 
Delirium in lobar pneumonia, 324 
Dementia prsecox, 499 
Dent on pyloric stenosis, 187 
Dentition, 170 

as cause of convulsions, 484 
of digestive disorders, 170 
convulsions, 170, 485 
disturbances of, 170 
Denys on blood transfusion, 786 

on phagocytosis, 797 
Depressed chest, 302 

fracture of skull, cephalhematoma 

and, differentiation, 143 
nipples, 35 
Dermatitis in pellagra, 739 
des Gabets on blood transfusion, 786 
Desquamation in German measles, 
625 
in scarlet fever, 646 
Detre's differential cutaneous reaction 

in tuberculosis, 702 
Development, abnormal, of child, 123 

normal, of child, 123 
Dew's method of artificial respiration 
in asphyxia neonatorum, 150 



Dextrinized barley-water, formula for, 

71 
Diabetes insipidus, 734 

mellitus, 735-737 
Diagnosis, 130 
by inspection, 131 
during sleep, 132 
Diaper, ammoniacal, 100 
Diaphoresis as means of relieving fever, 

746 
Diaphragmatic hernia, 757 
Diarrhea, cyclic, 719 
in lobar pneumonia, 324 
in mechanical intestinal disturbances, 

treatment, 214 
in typhoid fever, treatment, 664 
summer, instructions in, 767 
Diarsenol in acute hereditary syphilis, 

685 
Diesophagus, 171 
Diet after first year, 102 
after sixth year, 108 
common errors in, 110 
for delicate child, 124, 125 
from first to sixth year, 105 
in acute diffuse nephritis, 445 
salt-free, 446 
endocarditis, 381 
ileocolitis, 227 
gastric indigestion, 174 
illness, 135 

infective meningitis, 552 
in bronchitis, 312 
in bronchopneumonia, 337 
in chronic ileocolitis, 228 

valvular disease of heart, 391 
in colic, 215 

in constipation in older children, 242 
after fifth year, 243 
after second year, 242 
in convalescence from acute ileo- 
colitis, 226 
in convulsions, 486 
in diabetes mellitus, 737 
in diphtheria, 635 
in eczema, 588 
in epilepsy, 534 
in fissure of anus, 261 
in gastro-enteric intoxication, 198 

after first year, 200 
in habit spasm, 524 
in habitual loss of appetite, 80 
in icterus, 265 



876 



INDEX 



Diet in illness, 109 
art of, 109 
reduction of food strength, 109 

in laryngismus stridulus, 489 

in malnutrition, 93 

in marasmus, 88, 90 

in maternal nursing, 24 

in measles, 622 

in mucous colitis, 230 

in obesity, 752 

in pulmonary tuberculosis, 364 

in pyloric stenosis, 192 

in rachitis, 120 

after first year, 121 

in recurrent bronchitis, 315 

in rheumatism, 710 

in scarlet fever, 651 

in scurvy, 114 

in second summer, 105 

in stomatitis, 165 

in tardy malnutrition of syphilitic 
origin, 690 

in typhoid fever, 661 

of premature infants, 141 

proteid, in tetany, 497 

schedule for feeding after first year, 
106-108 

table of quantities, 111 
Digestion, gastric, 172 

stomach, duration of, 173 
Digestive disorders, climate in, 774 

from dentition, 170 
Digitalis, 783 

in chronic valvular heart disease, 392 

in lobar pneumonia, 330 
Dilatation, congenital, of esophagus, 171 

of colon, idiopathic, 230 

of stomach, chronic, 176 
in older children, 177-180 
vomiting from, 219 
Diminished breathing, 306 
Diphtheria, 625 

age incidence, 626 

antitoxin treatment, 632. See also 
Antitoxin treatment of diphtheria. 

bacillus of, 627 

bacteriology, 627 

carriers, 627 

diet in, 635 

heart stimulants in, 636 

history, 625 

immunization in, 634 

in scarlet fever, 648 



Diphtheria, incubation period, 630 
intubation in, 638-642 
laryngeal, 636 
leukocytosis in, 400 
multiple neuritis after, 542 

treatment, 545 
nasal, 637 

acute rhinitis and, differentiation, 

267 
chronic, 637 
pathology, 630 
predisposition, 626 
quarantine in, 634 
remedial measures in, 635 
Schick test in, 627-630 
susceptibility to, 627 
tonsillar, tonsillitis and, differentia- 
tion, 281 
transmission, 626 
Diplococcus intracellularis of Weich- 
selbaum, 557 
pneumoniae, 321 
Dipper, Chapin, 57 
Diseases, contagious, 608 

precautions for physician in, 609 
transmissible, 608 

through association, 608 
intermediary, 608 
Disorders of nutrition, 86 
Dispensary infants and children, rules 

for summer care, 765 
Distended chest, 303 
Diverticula, intestinal, congenital, 246 
Dochez, Draper and Peabody on acute 
poliomyelitis, 536, 538, 539, 
541 
on blood findings in poliomye- 
litis, 398 
Dochez on blood in acute poliomyelitis, 

536 
Dohle on blood findings in scarlet fever, 
399 
on scarlet fever, 643 
Dopter on parameningococcus, 558 
Double empyema, 359 
Douche, cold, 779 

Douglas and Wright on opsonins, 797 
Dover's powder in acute ileocolitis, 224 
Downes on surgical treatment of pyloric 

stenosis, 192 . 
Drainage, siphon, in empyema, 356 
Draper and Peabody on blood in acute 
poliomyelitis, 536 



INDEX 



877 



Draper, Peabody and Dochez on acute 
poliomyelitis, 536, 538, 539, 541 
on blood findings in poliomyelitis, 
398 
Dried-milk foods, proprietary, 72 
Drinking of water in acute illness, 134 
Dromomania, 498 
Drop jaw in adenoids, 295 
Drugs, 847 

counterirritant, 775 

dosage, 847 

for external use, 859 

for internal use, 847 

nauseating, 781 

unpalatable, 781 
Dry heat, 785 
Dubini's disease, 518 
Duchenne- Aran's disease, 526, 527 
Duke on hemorrhagic diseases of new- 
born, 160 
Dulness of chest, 304 

tympanitic, 304 
Duodenal ulcer, 184 
Dupre on meningismus, 565 
Duval and Bassett on acute ileocolitis, 

221 
Dwarfism, 733 
Dwarfs, 733 
Dyer on pellagta, 740 
Dysentery, 220. See also Ileocolitis^ 

acute. 
Dyslalia, 525 
Dyspituitarism, 428 
Dystrophy adiposogenitalis, 428 

muscular, primarj^, 530 

Ear changes in tardy hereditary syphi- 
lis, 686 

diseases of, 600 
Earache, 600 

in acute otitis, 602 
Ears in cerebrospinal meningitis, 560 

in measles, care of, 623 
Eberth's bacillus of typhoid, 657 
Eczema, 584 

age incidence, 585 

bathing in, 589 

carbon incapacity as cause, 585 

clothing in, 589 

eosinophiha in, 399 

etiology, 584 

euresol in, 589 

feeding in, 588 



Eczema, Herty mask in, 591 
in older children, 591 
bathing in, 595 
etiology, 592 
prognosis, 594 
symptoms, 593 
treatment, 594 
intertrigo, 590 
local, 595 

local irritation as factor, 586 
neurotic, 593 
physical condition in, 585 
prognosis, 586 
reflex, 593 
seborrheic, 595 
strait-jacket in, 591 
symptoms, 586 
toxic origin, 585 
traumatic, treatment, 589 
treatment, 586 
Edema, angioneurotic, 570 
Edgar on treatment of asphyxia neona- 
torum, 150 
Effusion, pleurisy with, 349 

pleuritic, in lobar pneumonia, 327 
purulent, pleurisy with, 351. See 
also Empyema. 
Egg-water, formula for, 70 
Egyptian chlorosis, 247 
Ehrlich on splenomyelogenous leuke- 
mia, 407 
Eisenberg on icterus neonatorum, 144 
Eiweiss milk, 65 

in acute ileocoUtis, 224 
in gastro-enteric intoxication, 201 
Electric chorea, 518 

irritability in tetanus, 495 
reactions in acute poliomyeUtis, 540 
in cerebral paralysis, 516 
in multiple neuritis, 544 
Electricit}' in acute poliomyelitis, 541 
Elimination as means of relieving fever, 

746 
Elliott on seborrhea intertrigo, 596 
Emaciation in cerebrospinal meningitis, 

562 
Emerson on blood findings in scarlet 
fever, 400 
on chondrodystrophia, 725 
on leukoc3'tosis in measles, 400 
in meningitis, 398 
in scarlet fever, 400 
in whooping-cough, 399 



878 



INDEX 



Emerson on polymorphonuclear neu- 
trophiles, 395 

on splenomyelogenous leukemia, 407 

on pseudoleukemia anemia, 406 
Emphysema, 346 

auscultation in, 347 

compressed-air bath in, 829 

deep breathing in, 828 

development of accessory muscles of 
expiration in, 829 

exercise in, 827-829 

Gerhardt's exercise in, 849 

McKenzie's exercise in, 828 

of mediastinum, 347 

pathology, 346 

percussion in, 347 

prognosis, 347 

rarefied air apparatus in, 829 

respiratory exercises in, 828 

Satterthwaite's method of artificial 
respiration in, 828 

subcutaneous, 347 

Sylvester's method of artificial res- 
piration in, 828 

symptoms, 346 

treatment, 347 
Emphysematous breathing, 307 
Empyema, 351 

after lobar pneumonia, 353 

age incidence, 351 

bacteriology, 351 

counterirritants in, 776 

deformity following untreated cases, 
356 

diagnosis, 354 
differential, 354 

double, 359 

encysted, as cause of elevation of 
temperature, 749 

etiology, 351 

exercises for, 793, 794 

in lobar pneumonia, 325 

leukocytosis in, 397 

malaria and, differentiation, 355 

necessitatis, 360 

pathology, 352 

pleurisy and, differentiation, 354 

pneumonia and, differentiation, 354 

pulmonary tuberculosis and, differ- 
entiation, 355 

staphylococcus vaccine in, 797 

Sylvester's method of artificial res- 
piration in, 825 



Empyema, symptoms, 352 
treatment, 355 

typhoid fever and, differentiation, 355 
Encephalocele, 499 

cephalhematoma and, differentiation, 

143 
hydrocephalus and, differentiation, 
143 
Endocarditis, acute, 377 
age incidence, 378 
antirheumatic treatment, 382 
auscultation in, 380 
bacteriology, 378 
convalescence in, 383 
diagnosis, 379 
diet in, 381 

diagnosis, differential, 380 
drugs in, 381 
etiology, 378 
ice-bag in, 381 
inspection in, 379 
palpation in, 379 
pathology, 378 
percussion in, 380 
prognosis, 380 
prolonged inactivity in, 381 
recurrence, 382 
rest in bed in, 380 
symptomatology, 379 
treatment, 380 
in scarlet fever, 648 
malignant, 378 
prognosis, 380 
Enema, nutrient, 83 

amount of nourishment, 85 
method of giving, 83 
nourishment not to be used, 84 

to be used, 85 
peptonized milk for, 68 
Enemas in colic, 215 

in constipation in nurslings, 239 
Engel on leukocytosis in diphtheria, 400 

on pyloric stenosis, 187 
English breast-pump, 35 
Enteric intoxication, acute, 201-203 
Enterocolitis as cause of convulsions, 

484 
Enuresis, 432-434 

of nervous origin, 433 
Environment and heredity, 743 

as factor in nutrition and growth of 
new-born infant, 17 
in artificial feeding, 48 



INDEX 



879 



Eosinophiles, 395 

Eosinophilia from parasitic infection, 
399 

in asthma, 399 

in congenital syphilis, 399 

in eczema, 399 
EosinophiUc myelocytes, 395 
Epidemic parotitis, 611-613 
Epilepsy, 531 

aura of, 532 

bromids in, 534 

care of bowels in, 534 

colony management, 534 

diagnosis, 533 

diet in, 534 

drugs in, 534 

grand mal, 532 

in birth form of cerebral paralysis, 515 

in cerebral paralysis, 517 

prognosis, 533 

treatment, 533 

types, 532 
Epiphysitis, acute, in acute hereditary 

syphilis, 681 
Epispadias, 464 

Epstein on icterus neonatorum, 143 
Erb on progressive amyotrophy, 530 
Erb's juvenile type of progressive 
amyotrophy, 530 

paralysis, 547 
Erysipelas, 581 

complications, 582 

convalescence in, 584 

etiology, 582 

ichthyol in, 583 

prognosis, 582 

stimulants in, 584 

streptococcus vaccine in, 800 

symptoms, 582 

treatment, 583 
Erythema intertrigo, 590 

multiforme, 581 

nodosum, 580 
Escherich on tetany, 492, 495 
Esophagotracheal fistula, 171 
Esophagus, absence of, 171 

congenital dilatation of, 171 

congenital stenosis of, 171 

diseases of, 162 

division of, 171 

malformation of, 171 

reduphcation of, 171 
Ether as anesthetic, 750, 751 



Ethyl chlorid as anesthetic, 751 
Euresol in eczema, 589 
Evaporated milk in malnutrition, 96 
Ewing on leukocytosis in measles, 400 
Exaggerated breathing, 306 
Examination, 130 

first, 132 

of urine in acute illness, 135 

of throat, 271 
Exercise, accuracy of execution, 804 

active, elevation of temperature 
from, 747 

adaptation to practical ends, 806 

attention to general health in, 805 

breathing, 806, 814 
for older children, 815 
for younger children, 815 

clothing for, 803 

concentration in, 805 

conditions necessary for, 803 

cooperation in, 806 

double mirrors during, 772 

duration, 804 

early, baskets for, 44 

examination before, 803 

for acute poliomyeUtis, 841 

for arms in anterior poliomy elitis, 
842 

for delicate children, 128 

for emphysema, 827-829 

for empyema, 793, 794 

for flat chest, 815 

for Friedreich's ataxia, 830, 841 

for general circulation in constipa- 
tion, 844 

for hereditary cerebellar ataxia, 829- 
841 
spinal ataxia, 829-841 

for kyphosis, 817 

for nursing mother, 25 

for round shoulders, 817 

for scoliosis, 822 

for speech in congenital ataxias, 
840 

for upper hmbs in congenital ataxias, 
840 

forms, 804 

frequency, 804 

Gerhardt's, in emphysema, 849 

in acute poliomyehtis, 542 

in bad posture, 809 

in constipation, 843 

in flat-foot, 844-846 



880 



INDEX 



Exercise in obesity, 752 

in talipes planus, 844-846 

ladder, in congenital ataxias, 837 

McKenzie's, in empli;^sema, 828 

modification, 805 

Naunyn's, for empyema, 825 

overwork in, 805 

passive, for constipation, 844 
in anterior poliomyelitis, 842 

pen, 767 

posture in, 806 

prescription of, 804 

respiratory, for emphysema, 828 

rest in, 805 

room temperature for, 803 

rules for, 803 

shot-bag, in bad posture, 811 

static, for bad posture, 811 

temporary discontinuance, 805 

with resistance, in constipation, 844 
Exhaustion, gavage in, 792 
Expansion, defective, of lungs, 303 
Expectorants in spasmodic croup, 

289 
Exstrophy of bladder, 458 

operative treatment, 459 
Eye changes in tardy hereditary syphilis, 

686, 688 
Eyes, care of, in measles, 622, 623 

in cerebrospinal meningitis, 560, 562 

in measles, 620 

Face, expression of, in adenoids, 295 

myopathic, 531 
Facial deformity, absence of, in ade- 
noids, 295 

paralysis, 546 
Faucial tonsils, 279 
Fagge on cretinism, 727, 728 
FalHng sickness, 531 
Family idiocy, amaurotic, 507-509 
Fat of modified cow's milk, 56 
Fatty change in liver, 264 
Faucitis, 273 

treatment, 274 
Faught sphygmomanometer, 401 
Fears, morbid, 498 
Feces. See Stools. 

incontinence of, 232 
treatment, 233 
Feeder, Breck, 141 

Feeding, artificial, 48. See also Arti- 
ficial feeding. 



Feeding, breast-, substitute, 48. See 
also Artificial feeding. 
by inunction, 82 

catheter, in pyloric stenoses, 193 
colonic, 83 

forced, 790. See also Gavage. 
frozen milk, 78 
hypodermic, 82 
malt-soup, 64 

in marasmus, 94 
mixed, 29 

of delicate child, 124, 125 
over-, 110 
rectal, 83 

amount of nourishment, 85 
in acute illness, 136 
method of giving, 83 
nourishment not to be used, 84 
to be used, 85 
scientific, 78 
starch-, 66 

stomach-, substitutes for, 81 
substitute, Chapin dipper for, 57 
ingredients required for, 72 
number of feedings, 58-61 
table of quantities, 111 
top-milk, 59 
whey-, 64 

in malnutrition, 94 
Feeling, beginning of, in new-born, in- 
fants, 43 
Feer on pyloric stenoses, 187 
Female genitals, diseases of, 465 
Fetal chondritis, 725 

rickets, 725 
Fever, 745 

as an indication, 745 
basin bath for, 780 
in acute otitis, 602 

retropharyngeal abscess, 277 
in bronchopneumonia, treatment, 341 
cold sponging in, 776 
in lobar pneumonia, treatment, 329 
methods of relieving, 746 
periodic, 720 
rheumatic, 721 
tub-baths for, 779 
Fibroma of brain, 502 

of kidney, 438 
Fievre cerebrale, 557 
Fildes on hemophilia, 411 
Finger-sucking, 478 
Finger-tips, picking and rubbing, 478 



INDEX 



881 



Finkelstein and Meyer's Eiweiss milk, 
65 

on icterus neonatorum, 144 

on leukocytosis in gastro-enteritis, 
399 

on pyloric stenosis, 188 

on spasmophilia, 489 
Fischl on tetany, 492 
Fish tape-worm, 249 
Fissures at angle of mouth, 168 

in acute hereditary syphihs, 681 

of anus, 260 

of lips, 167 
Fissured nipples, 34 
Fistula, esophagotracheal, 171 
Fixed chest, 303 
Flat chest, 304, 815 
Flat-foot, exercises for, 844-846 

massage in, 845 
Fleishmann on capacity of stomach, 184 
Flexner and Clark on acute poliomye- 

Htis, 537 
Flexner and Jobling on antimeningo- 
coccus serum, 800 
on cerebrospinal meningitis, 557 
Flexner and Lewis on acute poliomye- 
litis, 537 
Flexner and Noguchi on cause of 

anterior poliomyelitis, 535 
Flexner on acute poliomyelitis, 536, 537 
Flexner, Peabody and Draper on acute 

poliomyelitis, 536 
Flexner's serum in cerebrospinal men- 
ingitis, 563-565 
Floor of nursery, 36 
Floyd and Morse on bacteriology of 

chorea, 519 
Flushing, colon, 795 

technic, 796 
Fochsinger on tardy hereditary syphilis, 

686 
Folli on blood transfusion, 786 
Follicular tonsillitis, acute, 280 
Fontanel in cerebrospinal meningitis, 

560 
Food, advantage of knowledge of com- 
position, 103 

allergy, 79 

dried-milk, proprietary, 72 

elements, function of, 103 

formulas, 70 

general properties, 102 

idiosyncrasy to, 79 
56 



Food, ingredients, 103 

laxative agents in, in constipation in 

bottle-fed, 240 
malted, in constipation in nurslings, 

239 
proprietary, 71 

addition of fresh cow's milk, 73 
beef, 73 
retention in pyloric stenoses, 188 
selection and preparation for new- 
born infant, 19 
selection of, 104 

strength, reduction in, in illness, 109 
in summer, 763 
Foot, flat-, exercises for, 844, 846 

massage in, 845 
Forced feeding, 790. See also Gavage. 
Foreign bodies as cause of chronic 
rhinitis, 270 
in larynx, 292 
swallowed, 769 
Formulas, food, 70 
Fournier on tardy hereditary syphilis, 

685 
Fowler on leukocytosis in appendicitis, 

398 
Fowler's solution in chorea, 522 
Fox on cretinism, 728 
Fracture of skull, depressed, cephal- 
hematoma and, differentiation, 143 
Franck on icterus neonatorum, 143 
Frankel's pneumococcus, 321 
Frapoli on leprosy, 738 
Freeman on intestinal infantilism of 
Herter, 231 
on rickets, 115 
pasteurizer, 75 
Fremitus, vocal, in lobar pneumonia, 

327 
Friedlander's pneumobacillus, 321 
Friedleben on weight of thymus, 423 
Friedreich's ataxia, 548-550 

exercises for, 830, 841 
Fresh air for new-born infant, 19 
for premature infant, 141 
in habitual loss of appetite, 80 
in measles, 624 
in whooping-cough, 619 
Freund on pyloric stenosis, 186, 187 
Frohlich and Muenier on leukocytosis 

in whooping-cough, 400 
Frohlich 's dystrophy adiposogenitalis, 
42« 



882 



INDEX 



Frozen milk, 78 

Fumigations, calomel, in spasmodic 

croup, 290 
Functional heart murmurs, 370 
Funicular hydrocele, 463 
Funnel chest, 302 
Furniture, effect of, on posture, 808 

of nursery, 37 
Furunculosis, 573 

staphylococcus vaccine in, 799 

treatment, local, 573 
constitutional, 574 



Gaffky on Bacillus typhosus, 657 
Gait, waddling, in pseudomuscular 

hypertrophy, 531 
Galen on diphtheria, 626 
Ganghofner on tetany, 492 
Gangrene, pulmonary, 360 
Gant on intestinal cysts, 246 
Gardner on treatment of bronchiectasis, 

345 
Gastric digestion, 172 
hemorrhage, 182 
indigestion, acute, 173 

chronic, 175 
motility, 173 
Gastritis, acute, 173 
chronic, 175 
in influenza, 674 
Gastro-enteric diseases, cereal gruels in, 
67 
intoxication, 194 
acidosis in, 193 
acute, 193 

types, 194 
animal broths in, 199 
cereal decoctions in, 200 
condensed milk in, 200 
diet in, 198 
drugs in, 197 
Eiweiss milk in, 201 
evaporated milk in, 200 
feedings after first year in, 200 
hypodermoclysis in, 198 
milk substitutes in, 196 
pathology, 195 
proteid milk in, 201 
re-infection in, 199 
skimmed milk in, 198 
symptoms, 195 
termination, 197 



Gastro-enteric intoxication, treatment, 
196 

urine in, 195 
wet-brain in, 195 
wet-nurse in, 199 
Gastro-enteritis, leukocytosis in, 399 
Gastro-intestinal causes of convulsions, 
483 

symptoms in scarlet fever, 659 
Gaucher type of splenomegaly, 263 
Gavage, 790 

in exhaustion, 792 

in lobar pneumonia, 331 

in malnutrition, 792 

in multiple neuritis, 546 

in narcosis, 792 

in obstinate vomiting, 791 

in severe illness, 792 

peptonized milk for, 68 

stomach-tube for, 791 
Gengou.and Bordet bacillus, 614 
Genitals, female, diseases of, 465 

male, diseases of, 459 
Geographic tongue, 167 
Gerhardt's exercise in emphysema, 

849 
German measles, 624 
Getzowa on cretinism, 728 
Ghou on pulmonarj^ tuberculosis, 361 
Giant hives, 570 
Gibney on scurvy, 114 
Gilford on true dwarfism, 733 
Gittings and Carpenter on coagulation 

time of blood, 402 
Gland, thymus, 423 

enlargement of, 424. See also Status 
lymphaticus. 
Glands, tuberculous, 420 
Glandular fever, 419 

system, diseases of, 415 
Glioma of brain, 502 
Gliosarcoma of brain, 502 
Glisson on rickets, 115 

on scurvy. 111 
Globus hystericus in hysteria, 474 
Glycosuria, 437 

Gofl3.sey on tuberculous adenitis, 420 
Goldberg on pellagra, 738 
Goldberger and Anderson on measles, 

620 
Gonococcus vaccine, 800 
Gonorrhea in male, 464 

in nursery maids, 38 



INDEX 



883 



Gonorrheal arthritis, diagnosis, 757 

vulvovaginitis, 466 
Goodman on chorea, 523 
Gowers on brain tumors, 502 

on Friedreich's ataxia, 549 
Graham on hemorrhagic diseases of 

new-born, 160 
Grand mal type of epilepsy, 532 
Granuloma, umbilical, 154 
Gravity cream, 56, 73 
Gray hepatization in lobar pneumonia, 

321 
Greger on leukocytosis, 396 
Grip, 670. See also Influenza. 
Grooves, Harrison's, in rachitis, 118 
Growing pains, 709 
Gruel flours, percentage, formulas for, 

70, 71 
Gruels, cereal, 66 

for milk adaptation, 64 
Gull on cretinism, 727 
Gumma of brain, 502 
Gymnastic therapeutics, 803. See also 

Exercise. 
Gyrospasm, 472 

Habits, 477 

bad, correction of, 478 
Habit chorea, 520 

cough, 272 

spasm, 524 
Habitual loss of appetite, 79-81 
Hairy mole, 598 

Hamburger's tuberculin test for tuber- 
culosis, 701 
Hamilton and Cooke on gonococcus 

vaccine, 800 
Hand, accoucheur, in tetany, 494 
Hand-I-hold babe mitt, 482 
Hard ball stools, 46 
Harelip, 168 

Harrison's grooves in rachitis, 118 
Hay-fever, 301 
Hayem on red cells, 394 
Head, cold in, 267 

lice, 574 
Headache, 470 

in cerebrospinal meningitis, 560 
Head-banging, 478 
Head-rolling, 478 
Hearing in new-born infant, 42 
Heart action in cerebrospinal men- 
ingitis, 560, 562 



Heart disease, chronic valvular, 389. 

See also Valvular disease, chronic, 

of heart. 
congenital, 386 

cardiac enlargement in, 387 

classification of lesions, 387 

clubbed fingers in, 387, 388 

diagnosis, 387 

murmur in, 388, 389 

pathology, 386 

polycythemia in, 401 

prognosis, 386 

symptomatology, 386 
diseases of, 368 

auscultation in, 368 
diagnosis in, 368 
inspection in, 369 
palpation in, 370 
percussion in, 370 
thrill in, 372 
disturbance in acute infective men- 
ingitis, 550 
enlargement of, in congenital heart 

disease, 387 
involvement in scarlet fever, treat- 
ment, 655 
murmurs, cardiorespiratory, 373 
functional, 370, 372 

after acute illness, 374 

diagnosis, differential, 373 

during development, 374 

etiology, 373 

treatment, 374 
in aortic regurgitation, 372 
in aortic stenosis, 372 
in congenital heart disease, 388 
in mitral regurgitation, 371 
in mitral stenosis, 371 
inorganic, 370 
location of lesions by, 371 
non-valvular, 370 
organic, 370 
valvular, 370 
venous, 373 
rest in chronic valvular heart disease, 

392 
sepsis of, in new-born, 147 
sounds, first, 368 
normal, 368 
second, 368 
stimulants in bronchopneumonia, 340 
in chronic valvular disease, 392 
in diphtheria, 636 



884 



INDEX 



Heart stimulants in lobar pneumonia, 
329 
in typhoid fever, 665 
tuberculosis of, 363 
Heat, artificial, for premature infant, 
140 
as therapeutic agent, 784 
dry, 785 
local application of, in acute diffuse 

nephritis, 447 
moist, 784 
prickly, 569 
Heating of nursery, 37 
Hecker on leukocytosis in measles, 400 
Height, 41 

Heiman on icterus neonatorum, 144 
Hektoen on leukocytosis in measles, 400 
Heliotherapy in chronic tuberculous 
peritonitis, 698 
in pulmonary tuberculosis, 366 
Heller and Levin on syphilis, 686 
Hematemesis, 182 

Hematoma of sternocleidomastoid, 752 
Hematuria, 436 
Hemicephalus, 501 
Hemiplegia, 514, 516 
Hemoglobin, 394 

percentage of, in blood in new-born, 
394 
Hemoglobinuria, 436 

paroxysmal, 436 
Hemolysis, prevention of, in blood 

transfusion, 786 
Hemophilia," 411-413 
Hemorrhage from stomach, 182 
in acute hereditary syphilis, 681 
in typhoid fever, treatment, 666 
intestinal, in typhoid fever, 660 
nasal, treatment, 271 
Hemorrhagic diseases of new-born, 157 
bacteria as factor, 158 
chemical agents as etiologic fac- 
tor, 159 
heredity as etiologic factor, 159 
Kerley's treatment, 161 
mechanical means as etiologic 

factor, 159 
metabolic changes as etiologic 

factor in, 159 
serum treatment, 160 
syphilis as etiologic factor, 158 
treatment, 160 
Welch's treatment. 160 



Henoch's purpura, 409 
Hepatization, gray, in lobar pneu- 
monia, 321 

red, in lobar pneumonia, 321 
Heredity and environment, 743 

as cause of convulsions, 484 

as factor in hemorrhagic diseases of 
new-born, 159 
in nutrition and growth of new- 
born infant, 17 

effect of, on posture, 809 

in hysteria, 473 
Hereditary ataxia, 548-550 

cerebellar ataxia, exercises for, 829- 
841 

spinal ataxia, exercises for, 829-841 

syphilis, acute, 678. See also Syphi- 
lis, acute hereditary. 
tardy, 683. See also Syphilis, 
tardy hereditary. 
Hernia at umbilicus, 753 

congenital umbilical, 754 
treatment, 754 

diaphragmatic, 757 

inguinal, 755 

of umbilical cord, 753 

ventral, 756 
Herter, intestinal infantilism of, 231 
Herty mask in eczema, 591 
Hess bulb in pyloric stenosis, 189 

on feeding in pyloric stenosis, 193 

on icterus neonatorum, 144 

on pyloric stenosis, 191 

on starch digestion, 68 
Heubner on calorimetric principles in 
infant feeding, 66 

on cerebrospinal meningitis, 557 
Hiccup, 483 

Hip, tuberculosis of, diagnosis, 758 
Hirsch on amaurotic family idiocy, 507 
Hirschfeld on rachitis, 117 
Hirschsprung's disease, 230 

theory of pyloric stenosis, 187 
Hirt on etiology of chorea, 519 
Hirth on cerebrospinal meningitis, 557 
History record, 132 
Hives, 570. See also Urticaria. 
Hodgkin's disease, 413 
Hoffmann and Schaudinn on Spirochseta 

palhda, 677 
Hoffmann and Werdnig on progressive 

amyotrophy, 526 
Hofmeier on icterus neonatorum, 143 



INDEX 



885 



Hofmeister on icterus neonatorum, 143 

Holb on tetany, 493 

Holberstein on icterus neonatorum, 143 

Hollander on stammering, 526 

Holt and Brown on salvarsan in syphilis, 

684 
Holt on average weight of house- 
clothing, 40 
of new-born infant, 39 

on blood findings in leukocytosis, 400 

on capacity of stomach, 172 

on deafness in scarlet fever, 655 

on duodenal ulcer, 184 

on enlargement of thymus gland, 425 

on eosinophilia in asthma, 399 

on hydrocephalus, 510 

on intussusception, 234 

on leukocytosis in measles, 400 
in scarlet fever, 400 

on pyloric stenosis, 186 

on siphon drainage in empyema, 356 

on splenomyelogenous leukemia, 407 

on temperature elevation, 749 

on tetanus neonatorum, 156 

on tuberculous adenitis, 420 
Home on diphtheria, 626 
Hoobler and Howland on blood-pressure 

in pneumonia, 402 
Hoobler on blood-pressure, 401 
Hook-worm, 250 

Hopping in congenital ataxias, 839 
Horsley on cretinism, 727 
Hot applications in acute ileocolitis, 225 
in colic, 216 

bath, 781 
Howitz on cretinism, 728 
Howland and Hoobler on blood-pressure 

in pneumonia, 402 
Howland and Marriot on spasmophilia, 

489 
Howland on blood-pressure, 401 

on hypodermoclysis, 796 
Human milk, 31. See also Breast-milk. 

serum in acute poliomyelitis, 541 
Hutchinson teeth in tardy hereditary 

syphilis, 688 
Hutinel on blood-pressure, 401 
in contagious diseases, 402 
Hydrencephalocele, 499 
Hydrocele, 463 

common vaginal, 464 

congenital, 463 

funicular, 463 



Hydrocele, infantile, 463 
inguinal hernia and, differentiation, 

755 
of cord, 463 

encysted, 464 
of tunica vaginaUs, 464 
treatment, 464 
varieties, 463 
Hydrocephalus, 509 
acquired, 509 
congenital, 510 
diagnosis, 512 
duration, 511 

encephalocele and, differentiation, 143 
external, 509 
chronic, 510 
congenital, 510 
internal, 509 
acute, 510 
chronic, 510 
prognosis, 512 

rachitis and, differentiation, 120 
symptoms, 510 
treatment, 512 
Hydromyelocele, 501 
Hydronephrosis, 439 
Hydrotherapy in lobar pneumonia, 

329 
Hygiene in pulmonary tuberculosis, 
365 
in rachitis, 121 
Hyperemia treatment of persistent 

simple adenitis, 418 
Hypernephroma of kidney, 439 
Hyperplastic chondrodystrophia, 725 
Hyperpyrexia, 745 

Hypertrophy of turbinated bones, as 
cause of chronic rhinitis, 269 
pseudomuscular, 530 
Hypodermic feeding, 82 

medication in bronchopneumonia, 
340 
in convulsions, 486 
stimulation in lobar pneumonia, 331 
Hypodermoclysis, 796 
Hypoplastic chondrodystrophia, 725 
Hypospadias, 464 
Hypostatic pneumonia, 345 
Hysteria, 472, 498 
convulsive cases, 474 
diagnosis, 475 
drugs in, 477 
duration, 475 



886 



INDEX 



Hysteria, etiology, 473 

globus hystericus in, 474 

heredity in, 473 

imitation in, 473 

mental activity in, 476 

motor type, 474 

physical activity in, 476 

sensory type, 475 

symptoms, 474 

treatment, 475 

during seizure, 477 
Hysteric mania, 498 

Ibrahim on pyloric stenosis, 186 
Ice-bag in acute endocarditis, 381 
Ichthyol in erysipelas, 583 
Icterus, 265 
catarrhal, 265 
neonatorum, 143-145 
obstructive, 265 
Idiocy, 503 

amaurotic family, 507-509 
cretinoid, 727. See also Cretinism. 
Mongohan, 503-505 
Idiopathic dilatation of colon, 230 
Idiosyncrasy to cow's milk, in malnu- 
trition, 98 
to foods, 79 
Ileocolitis, acute, 220 

associated lesions, 222 
bacteriology, 221 
climatic influence, 226 
colon irrigation in, 225 
diet in convalescence, 226 
drugs in, 224 
duration, 223 

obstinate constipation in, treat- 
ment, 227 
pathology, 221 
symptoms, 222 
treatment, 223 
chronic, 227 

colon irrigation in, 229 
constipation in, treatment, 229 
diet in, 228 
symptoms, 228 
treatment, 228, 229 
pseudomembranous, 222 
severe, 222 
simple catarrhal, 221 
ulcerative, 222 
Ileus, paralytic, 245 
treatment, 202 



Illness, acute, attendants, 134 
bowel feedings, 136 

function in, 136 
care of, 130 

essentials in, 133 
clothing, 134 

essentials in care, cold air, 134 
diet, 135 

drinking of water, 134 
drugs, 136 

examination of urine, 135 
keeping in bed, 133 
needless interference, 135 
room temperature, 134 
sick-room, 134, 137 , 
sponging, 134 
stimulation, 137 
ventilation, 134 
window-board, 138 
nephritis in, 135 
pyrexia in, treatment, 136 
diet during, 109 

reduction in food strength, 109 
Imbecility, 503 
Imitation in hysteria, 473 
Immerman on hemophilia, 412 
Immunity, 797 

in acute poliomyelitis, 537 
in diphtheria, 634 
in typhoid, duration, 659 
Imperative concepts, 498 
Imperial granum water, formula for, 

70 
Impetigo contagiosa, 579 
Incision, exploratory, in appendicitis, 

254 
Incontinence of feces, 232 

of urine, 432-434 
Incubators, baby, defective air supply 

in, 140 
Index, opsonic, 798 

phagocytic, 798 
Indigestion, gastric, acute, 174 
chronic, 175 
intestinal acute, 204 
persistent, 205 

in older children, treatment, 207 
Individual child, treatment and care of, 

139 
Infant, new-born, 17. See also New- 
horn infant. 
Infantile atrophy, 86. See also Maras- 



INDEX 



887 



Infantile convulsions, 483. See also 
Convulsions. 

hydrocele, 463 

myopathy of facioscapulohumeral 
type, 530 

myxedema, 727. See also Cretinism. 

paralysis, 535. See also Poliomyelitis, 
acute. 

scurvy, 112 
Infantihsm, intestinal, of Herter, 231 

symptomatic, 733 
Infectious diseases, cereal gruels in, 67 
Influenza, 670 

acute rhinitis and, differentiation, 268 

adenitis in, 675 

age incidence, 671 

bacteriology, 670 

bronchitis in, 674 

bronchopneumonia in, 674 

change of climate in, 677 

climate in, 773 

colitis, 674 

complications, 674 

cough in, 672 
treatment, 676 

diagnosis, 675 

drugs in, 677 

duration, 675 

etiology, 670 

external treatment, 677 

fatal cases, 674 

gastritis, 674 

gastro-intestinal manifestations, 673 

incubation period, 672 

kidneys in, 675 

leukocytosis in, 397 

mode of entrance, 671 

nephritis in, 675 

otitis in, 674 

pathology, 671 

persistent fever in, 675 

prognosis, 675 

quarantine in, 676 

sequelae, 675 

source of infection, 671 

symptoms, 672 

temperature in, 674 

treatment, 676 
Ingelev on scurv^^. 111 
Inguinal adenitis, 417 

glands, enlarged, inguinal hernia 
and, differentiation, 756 

hernia, 755 



Inhalations, steam, in bronchitis, 312 
in bronchopneumonia, 338 
in spasmodic croup, 290 
. stimulant, in acute spasmodic bron- 
chitis, 319 
Inorganic heart murmurs, 370 
Insanity, 497 
choreic, 518 
Inspection, diagnosis by, 131 
during sleep, 132 
in acute endocarditis, 379 
in diseases of heart, 369 
of chest, 302 
of lungs, 302 
Interstitial pneumonia, 342. See also 

Pneumonia, interstitial. 
Intertrigo, prevention of, 568 
Intestinal cj^sts, 246 

diseases of summer, etiologic factors, 
216 
importance of prompt treatment 

217 
prevention, 216 

dispensary rules for, 217 
how to secure good milk, 218 
necessity of education for, 

218 
New York City experiments, 
217 
diverticula, congenital, 246 
hemorrhage in typhoid fever, 660 
indigestion, acute, 204 
persistent, 205 

in older children, 206 
infantilism of Herter, 231 
infection as cause of elevation of 
temperature, 749 
with defective bowel action, treat- 
ment, 202 
intussusception, 233-236 
obstruction, 244 
parasites, 247 

blood in infections by, 247 
as cause of convulsions, 484 
tract, mechanical agencies in, diges- 
tive disturbances from, 
208 
constipation in, treat- 
ment, 213 
diarrhea in, treatment, 214 
massage in, 213 
medication in, 213 
symptoms, 208 



888 



INDEX 



Intestines, diseases of, 172 
invagination of, 233-236 
sepsis of, in new-born, 147 
tuberculosis of, 364 
Intoxication, acute enteric, 201-203 
gastro-enteric, 194. See also Gastro- 
enteric intoxication. 
Intubation in diphtheria, 638-642 
Intussusception, 233-236 

peritonitis and, differentiation, 257 
appendicitis and, differentiation, 254 
Invagination of intestines, 233-236 
Inward convulsions, 485 
lodid of potash, 782 
Ipecac, 782 

Iphophon on cretinism, 728 
Irrigation, colon, 793 

in acute enteric intoxication, 203 

ileocolitis, 225 
in chronic ileocolitis, 229 
technic, 794 
of throat, 278 

in peritonsillar abscess, 284 
indications, 278 
technic, 278 
Iron, tincture of muriate, 783 
Ischiorectal abscess, 262 
Italian leprosy, 738 
Itch, 572 
Ivy poisoning, 571 

Jackson on treatment of nsevus, 599 
Jacobi and WoUstein on tuberculosis, 

693 
Jacobi on cerebrospinal meningitis, 557 
Janeway on causes of hypotension, 402 

on chronic valvular disease of heart, 
389 
Japha on leukocytosis, 396 
Jaundice, 143-145 

catarrhal, 265 

obstructive, 265 
Javal on salt-free diet in acute nephritis, 

446 
Jaw, drop, in adenoids, 295 
Jobling and Flexner on antimeningo- 
coccus serum, 800 
on cerebrospinal meningitis, 557 
Jochmann and Krause on whooping- 
cough, 614 
Joint diseases, diagnosis, 757 

tuberculosis, diagnosis, 758 
Joints, sepsis of, in new-born, 146 



Jumping in congenital ataxias, 839 
Junket, formula for, 71 
Jurgensen on scarlet fever, 643 
Juvenile type of progressive amyo- 
trophy, Erb's, 530 

Karo on pyloric stenosis, 187 
Karznicki on transitional cells, 395 
Kassowitz's theory of tetany, 492 
Keller and Czerny on excessive am- 
monia excretion, 100 
Kenyon on siphon drainage in em- 
pyema, 356 
Kernig's sign in cerebrospinal menin- 
gitis, 561 
in tuberculous meningitis, 555 
Key-note position in scoliosis, 824 
Kidney, cysts of, 441 
diseases of, 438 
in influenza, 675 
new-growths of, 438 
of scarlet fever, 442 
tuberculosis of, 364, 438 
tumors of, 439 
Kindt on hernia of umbilical cord, 753 
King on blood transfusion, 786 
Kingdon on amaurotic family idiocy, 

509 
King's cough, 614 
Kinkcough, 614 

Kirchoff on heredity in insanity, 497 
Kitasato on tetanus bacillus, 156 
Klebs-Loffler bacillus, 626 

infection by, as cause of chronic 

rhinitis, 269 
persistent nasal infection with, 637 
Kleptomania, 498 
Knee-crutch to prevent masturbation, 

480 
Knoepfelmacher on acute poliomyelitis, 
537 
on hemorrhagic diseases of new-born, 
159 
Koch on hemophilia, 412 
Kocher on cretinism, 728 
Kolmer on blood findings in scarlet 
fever, 401 
on scarlet fever, 643 
Kolossowa on blood-pressure, 401 
Koplik and linger on Schick test, 628 
Koplik on age in cerebrospinal menin- 
gitis, 559 
on blood in anemia, 403 



INDEX 



889 



Koplik on epilepsy, 532 

on localization of lobar pneumonia, 

322 
on leukocytosis in pneumonia, 397 
on Still's disease, 724 
spots in measles, 621 

Koplik's method in asphyxia neona- 
torum, 150 

Korsakoff on bacteriology of glandular 
fever, 419 

Krause and Jochmann on whooping- 
cough, 614 

Kretschmar on scarlet fever, 643 

Krumwiede and Park on bovine tuber- 
culosis, 691 

Kyphosis, exercises for, 817 

Laborde's method of artificial respira- 
tion in asphyxia neonatorum, 150 

Lactalbumin of cow's milk, 49 

Lactic acid milk, 65 

Lactose of cow's milk, 49 

Ladder exercises in congenital ataxias, 
837 

La Fetra on acute spasmodic bronchitis, 
319 
on blood findings in poliomj^elitis, 
398 

Lamar and Meltzer on Diplococcus 
pneumoniae, 321 

Lamb on calorimetric principles in in- 
fant feeding, 66 

Lambert on hemorrhagic diseases of 
new-born, 160 

Landau on hemorrhagic diseases of new- 
born, 159 

Landouzy-Dejerine type of progressive 
amyotrophy, 530 

Landsteiner and Papper on acute polio- 
myelitis, 536 

Landsteiner on acute poliomyelitis, 537 
on scarlet fever, 643 

Langer on sclerema neonatorum, 145 

Langhans on cretinism, 729 

Langstein on diabetes mellitus, 735 

Laryngeal diphtheria, 636 
obstruction, 292 
stridor, congenital, 491 

in laryngismus stridulus, 487 

Laryngismus stridulus, 487-489 

Laryngitis, acute catarrhal, 287. See 
also Spasmodic croup. 
traumatic, 291 



Larynx, foreign bodies in, 292 

tuberculosis of, 364 
Lavage, 788 

in marasmus, 90 

in vomiting in infants, 185 

indications, 789 

intestinal, in typhoid fever, 666 

technic, 788 
Laxatives in scarlet fever, 652 
Leclef on phagocytosis, 797 
Leg-rubbing, 480 
Leiner and v. Weisner on acute polio- 

mj-elitis, 537 
Leishmania infantum, 263 
Lenz on precocious maturity, 457 
Leprosy, Italian, 738 
Leukemia, 407 

Leukocytes found in pathologic con- 
ditions, 395 
Leukocytosis, 396 

absolute, 396 

pathologic, 396 

physiologic, 396 

relative, 396 
Levaditi and Netter on acute poHo- 
myehtis, 537, 540 

on acute poliomyehtis, 537 

on scarlet fever, 643 
Levin and Heller on syphilis, 686 
LeWald and Smith on position after 

feeding, 94 
Lewis and Flexner on acute poliomye- 
litis, 537 
Lice, head, 574 

Limbeck on leukocytosis in tubercu- 
losis, 398 
Lind and Van Cott on trichiniasis, 251 
Lindemann method of blood transfusion 
in secondary anemia, 404 

on blood transfusion, 786 
Lingual tonsils, 279 
Lips, fissures of, 167 
Liver, abscess of, 264 

atrophy of, acute yellow, 264 

cirrhosis of, 264 

diseases of, 263 

in acute hereditary syphilis, 680 

in leukemia, 408 

in tardy hereditary syphiHs, 688 

tuberculosis of, 363 
Lobar pneumonia, 320. See also Pneu- 
monia, lobar. 
Long sigmoid, 208 



890 



INDEX 



Loss of appetite, habitual, 7^81 
Lowenburg on spasmophilia, 490 
Lower on blood transfusion, 786 
Lucas and Osgood on acute polio- 
myelitis, 537 
and Prizner on measles, 620 
Lucretius on epilepsy, 531 
Luetin test in syphilis, 706 
Lumbar puncture in acute infective 
meningitis, 552 
in meningismus, 566 
in tuberculous meningitis, 555 
method, 566 
needle for, 566 
position of patient, 566 
site for, 566 
uses, 567 
Lungs, acute pneumococcus infection 
of, 316 
auscultation of, 304 
consolidation of, in lobar pneumonia, 

326 
defective expansion of, 303 
diseases of, 302 
dulness of, 304 

tympanitic, 304 
examination of, 302 
inspection of, 302 
palpation of, 303 
percussion of, 303 
resonance of, 303 
tympanitic, 304 
sepsis of, in new-born, 147 
Lymphadenoma, 413 
Lymphatic glands, diseases of, 415 

enlargement of, in German measles, 
625 
leukemia, 407 
Lymphatism, 424. See also Status 

lymphaticus. 
Lymph-glands, cervical, tuberculosis of, 

364 
Lymph-nodes, cervical, tuberculosis of, 
420 
in Hodgkin's disease, 414 
in leukemia, 408 

in tardy hereditary syphilis, 686, 688 
Lymphocytes, 394 
Lymphomata in leukemia, 408 
Lysins, 797 

Mackenzie on cretinism, 728 
MacLeod on diabetes mellitus, 735 



Maid, nursery, 38 
Malaria, 666 

diagnosis, 668 
differential, 669 

empyema and, differentiation, 355 

mosquito transmission, 667 

pathology, 667 

physical examination, 668 

Plasmodia of, species, 667 

prophylaxis, 669 

quinin in, 669 

recurrence, 670 

relapse in, 668 

symptoms, 668 

transmission, 667 

treatment, 669 

yerberzine in, 669 
Male genitals, diseases of, 459 

gonorrhea in, 464 
Malformation of brain, 499 

of esophagus, 171 

of individual lobes of brain, 501 

of spinal cord, 499 
Mallory on pathology of typhoid, 658 

on scarlet fever, 644 
Malnutrition, 92 

as cause of chronic rhinitis, 270 

climate in, 774 

diagnosis, 93 

diet in, 93 

etiology, 92 

gavage in, 792 

idiosyncrasy to cow's milk in, 98 

in older children, 100 

symptoms, 92 

tardy, 100 

of syphilitic origin, 689 
treatment, 690, 691 

treatment, 93 
Malted foods in constipation in nurs- 

Ungs, 239 
Malt-soup feeding, 64 
in marasmus, 94 
Mammary abscess in new-born, 155 
Mania, 499 

hysteric, 498 
Mann and Danielson on cerebrospinal 

meningitis, 557 
Marasmus, 86 

age of occurrence, 86 

cow's milk in, 91 

etiology, 86 

feeding in, 90 



INDEX 



891 



Marasmus, history, 86 
infection as cause, 87 
lavage in, 90 
pathology, 86 

pyloric obstruction as cause, 87 
sweetened condensed milk in, 91 
treatment, 87^ 
outdoor, 89 

where wet-nurse is impossible, 90 
wet-nursing in, 88 
Market milk, 50 
Marriot and Rowland on spasmophilia, 

489 
Martin on diphtheria, 626 
Mask, Herty, in eczema, 590 
Mason on localization of lobar pneu- 
monia, 322 
on marginal pneumonia, 326 
on starch digestion in infant, 68 
Massage in acute poliomyelitis, 542 
in anterior poliomyelitis, 843 
in constipation in nurslings, 239 
in mechanical intestinal disturbances, 
213 
Mast cells, 395 
Mastitis, acute, 36 
in new-born, 155 
in young girls, 422 
suppurative, 36 
Mastoiditis, 606 
Masturbation, 479 
brace to prevent, 481 
Hand-I-hold mitt to prevent, 482 
knee-crutch to prevent, 480 
prophylaxis, 480 
treatment, 480 
Maternal nursing, 21 

air and exercise for mother in, 25 
care of nipples in, 31 
conditions forbidding, 29 
constipation in mother in, treat- 
ment, 25 
diet in, 24 
frequenc}^, 26 
management of abnormal milk 

conditions, 28 
mixed feeding, 29 
regularity in, 25 
signs of insufficient, 28 
of successful, 26 
of unsuccessful, 26 
temporary discontinuance of, 30 
water for mother in, 26 



Mathews on operation for removal of 

tonsils and adenoids, 298 
Maturity, precocious, 456 
May on deafness in scarlet fever, 655 
McCallum and Voegtlin on spasmo- 
philia, 489 
on tetany, 494 
McKenzie's exercise in emphysema, 828 
McKernon on treatment of acute 

otitis, 605 
Measles, 619 

age incidence, 620 
bath5 in, 623 

bronchopneumonia in, 621 
care of bowels in, 623 
complications, 621 
cough in, 620 

treatment, 623 
diagnosis, 621 
diet in, 622 
ears in, care of, 623 
etiology, 620 
e^^es in, 620 

care of, 622, 623 
feeding in, 622 
fresh air in, 624 
German, 624 
incubation period, 620 
Koplik spots in, 621 
.leukocytosis in, 400 
nephritis in, 622 
ner\^ous manifestations, 620 
otitis in, 621 
prognosis, 622 
quarantine in, 624 
rash in, 621 

delayed, 623 
recurrence, 622 
second attack, 622 
sjmiptoms, 620 
temperature in, 621 
transmission, 619 
treatment, 622 
vapor, 624 
Mechanical agencies in intestinal tracts 
digestive disturbances 
from, 208 
constipation in, treatment 

213 
diarrhea in, treatment,214 
massage in, 213 
medication in, 213 
symptoms, 208 



892 



INDEX 



Mediastinum, emphysema of, 347 

Melancholia, 498 

Meloena neonatorum, 158 

Meltzer and Lamas on Diplococcus 

pneumoniae, 321 
Membranous non-diphtheric angina in 
diphtheria, 647 
proctitis, 261 
Memory, beginning of, in new-born 

infants, 43 
Mendel and Rose on creatin excretion 

in starvation, 663 
Meniere's disease in tardy hereditary 

syphilis, 686 

Meningismus, 565 

diagnosis, 565 

differential, 565 
lumbar puncture in, 566 
symptoms, 565 
treatment, 566 
Meningitis, acute infective, 550-552 
cerebrospinal, 557. See also Cere- 

brospinal meningitis. 
in lobar pneumonia, 325 
leukocytosis in, 398 
serous, 565 
tuberculous, 553 
age incidence, 553 
diagnosis, 555 
differential, 556 
duration, 556 
Kernig's sign in, 555 
lumbar puncture in, 555 
pathology, 553 
prognosis, 556 
symptoms, 553 
treatment, 557 
Meningocele, 499 

of spinal cord, 501 
Meningococcus intracellularis, 557 
normal strain, 558 
parameningococcus strain, 558 
vaccine, 800 
Mensi on sclerema neonatorum, 145 
Menstruation, precocious, 456 
Mental apathy in cerebrospinal menin- 
gitis, 560 
deficiency, 503 

institutional treatment, 506 
treatment, 505 
unclassified cases, 503 
development of new-born infant, 42 
impairment in cerebral paralysis, 517 



MentaHty in cerebral paralysis, 515 
Mercury bichlorid, 782 

in acute hereditary syphihs, 682-684 
Mesenteric gland, tuberculosis of, 364, 

694 
Metabolic changes as etiologic factor in 
hemorrhagic diseases of new-born, 
159 
Metchinkoff on phagocytosis, 797 
Meyer and Finkelstein's Eiweiss milk, 
65 
on adenoids, 293 
Meyers on sclerema neonatorum, 145 
Microcephalus, 500 
Micrococcus lanceolatus, 321 
Micromelia, 725 
Middle-ear disease, 601. See also 

Otitis, acute. 
Miliaria, 569 

Milk, breast-, 31. See also Breast-milk. 
certified, 50 

requirements of New York County 
Medical Society Milk Commis- 
sion for production, 51 
rules for producer, 51-54 
condensed, in gastro-enteric intoxica- 
tion, 200 
in malnutrition, 95 
cow's, 49 

adaptation of, 54, 62 

by alkalis and antacids, 63 

by cereal gruels, 64 

by malt-soup extract, 64 

feeding, 64 
by sodium citrate, 63 
by whey-feeding, 64 
symptomatic, 62 
casein of, 49 
examination, 54 
fat of, modification, 56 
fresh, added to proprietary foods, 

73 
harmful bacteria in, 50 
idiosyncrasy to, in malnutrition, 

99 
in malnutrition, 94 
in marasmus, 91 
lactalbumin of, 49 
lactose of, 49 
legal standards for, 50 
market, 50 

mixed dairy, analysis, 55 
mixtures with cream, 57, 58 



INDEX 



893 



Milk, cow's, modified, 54 
aim of, 55 
by cream and milk mixtures, 56- 

58 
by dilution, 55 
by skimming, 57 
by top-milk methods, 59 
fat of, 56 

formulas for, 58-61 
proteid of, 55 
sugar of, 56 
plain, in malnutrition, 98 
proteids of, 49 

modification, 55 
quality variable, 61 
raw, advantages of, if pure, 76 
skimmed, mixtures of, 57 
solids of, 49 
stools from, 46 
sugar of, modification, 56 
crust, 595 

diet in scarlet fever, 651 
Eiweiss, 65 

in gastro-enteric intoxication, 201 
evaporated, in gastro-enteric intoxi- 
cation, 200 
in malnutrition, 96 
for traveling, 69 
frozen, 78 

general properties of, 104 
good, how to secure, 218 
human, 31. See also Breast-milk. 
in typhoid fever, 663 
infection of, tuberculosis from, 693 
lactic acid, 65 
pasteurization of, 74 

advantage and value of, 75 
effect on assimilation, 77 
peptonized, 68 
completely, 69 
for gavage, 68 
for nutrient enema, 68 
partially, 69 
processes, 69 
polluted, as cause of septic sore 

throat, 286 
protein, 65 

in gastro-enteric intoxication, 201 
safe, how to obtain in summer, 764 
selection of, in summer, 763 
skimmed, in gastro-enteric intoxica- 
tion, 198 
sterilization of, 74 



Milk, substitutes in gastro-enteric in- 
toxication, 196 

sweetened condensed, in marasmus, 
91 

withdrawal of, in summer, 763 
Miller and Wilcox on pyloric stenosis, 

187 
Miller on pyloric stenosis, 187 

on salt-free diet in acute nephritis, 446 
Miner's anemia, 247 
Minkowski on diabetes mellitus, 735 
Mirrors, double, during exercise, 772 
Mitral regurgitation, heart murmur in, 
371 
treatment, 391 

stenosis, heart murmur in, 371 
treatment, 391 
Mitt, Hand-I-hold, 482 
Modified milk, 54. See also Milk, 

cow's, modified. 
Moist heat, 784 

rales, 307 
Mole, hairy, 598 
Moller on scurvy. 111 
Moller-Barlow's disease, 112. See also 

Scuruy. 
Mongolian idiocy, 503-505 

rachitis and, differentiation, 120 
Mongolianism, 503-505 
Mononuclears, large, 395 
Monti on rachitis, 117 
Morbid fears, 498 
Morbus comitialis, 531 

Herculeus, 531 

sacer, 531 
Moro on leukocytosis, 396 

on starch digestion, 68 

tuberculin inunction test in tuber- 
culosis, 702 
Morse and Floyd on bacteriology of 

chorea, 519 
Morse on acute retropharyngeal ab- 
scess, 276 

on leukocytosis in diphtheria, 400 

on precocious menstruation, 456 
Mosher's kindergarten chair, 808 
Mosquito in etiology of malaria, 667 
Mother, breast of, 34 

nursing, 21. See also Maternal nurs- 
ing. 
Motility of stomach, 173 
Mouth, diseases of, 162 

toilet in typhoid fever, 661 



894 



INDEX 



Mouth, ulcerations and fissures at 

angle, 168 
Mouth-breathing in adenoids, 294 
Mouth-washing in stomatitis, 165 
Mucous colitis, 229 

membrane, respiratory, in tardy her- 
editary syphilis, 686 
patches in acute hereditary syphilis, 

681 
rales, 307 
Mucus in stools, 47 
Muenier and Frohlich on leukocytosis 

in whooping-cough, 400 
Mliller on acute poliomyelitis, 539 

on blood-findings in poliomyelitis, 398 
Multiple neuritis, 542. See also Neu- 
ritis, multi-pie. 
Mumps, 611-613 
Muriate of iron, tincture, 783 
Murkel on weight of thymus, 423 
Murmurs, heart, 370. See also Heart 

murmurs. 
Murmur, regurgitant, 370 

stenotic, 370 
Murray on cretinism, 727 
Muscle irritability in tetany, 494 
rigidity in cerebrospinal meningitis, 
560 
localized in appendicitis, 253 
Muscular atrophies, progressive, 526 
atrophy, progressive spinal, Charcot- 
Marie-Tooth type, 527 
claw-hand in, 527 
course, 528 

Duchenne-Aran type, 527 
etiology, 526 
hand type, 527 
leg type, 527 
peroneal type, 527 
prognosis, 528 
spastic type, 527 
pathology, 526 
symptoms, 527 
treatment, 528 
primary dystrophy, 530 
Musical rales, 307 
Mustard bath, 780 
Mutton broth, formula for, 70 
Mycotic stomatitis, 162 
Myelocystocele, 501 
Myelocytes, 395 

eosinophilic, 395 
Myelomeningocele, 501 



Myers on micturition in new-born, 429 

on temperature, 744 
Myocarditis, 383-385 

acute parenchymatous, 383 
suppurative, 383 

chronic interstitial, 384 

in lobar pneumonia, 325 

in scarlet fever, 648 
Myopathic face, 531 
Myopathies, 526 

Myopathy, infantile, of facioscapulo- 
humeral type, 530 
Myxedema, infantile, 727. See also 

Cretinism. 

N^vus, 598 
flammeus, 598 
linearis, 598 
lipomatodes, 598 
pilosus, 598 
pilus, 598 
vascular, 598 
verrucosus, 598 
Nails in acute hereditary syphilis, 681 
Nap, midday, for delicate children, 128 
Narcosis, gavage in, 792 
Nasal catarrh, 269 
diphtheria, 637 
chronic, 637 
hemorrhage, 271 
infection, persistent with Klebs- 

Loffler bacillus, 637 
mucous membrane in transmission of 
acute poliomyelitis, 537 
Naunyn's exercise for empyema, 825 
Nauseating drugs, 781 
Necrobiosis in stomatitis, 164 
Needle for lumbar puncture, 566 
Neisser on Wassermann test for syphilis, 

704 
Neosalvarsan in acute hereditary syph- 
ilis, 684, 685 
Nephritis, acute diffuse, 441 
bath in, 446 
bowels in, 446 
colon flushing in, 447 
convalescence in, 449 
convulsions in, 444 
diagnosis, 444 
diet in, 445 
duration, 444 
etiology, 441 
examination of urine, 444 



INDEX 



895 



Nephritis, acute diffuse, fever in, 443 
fulminating cases, 444 
local application of heat in, 447 
pathology, 442 
prognosis, 444 
salt free diet in, 446 
symptoms, 443 
time of development, 443 
toxic agents in etiology, 441 
treatment, 445 

of severe cases, 446 
urea excretion in, 448 
uremia in, 444 

treatment, 448 
urine in, 443 
interstitial, 442 
chronic diffuse, 449 

interstitial, 452 
climate in, 774 
in acute illness, 135 
in influenza, 675 
in measles, 622 
in scarlet fever, 648 
treatment, 655 
Nervous cough, 272 

disorders, 470 
Netter and Levaditi on acute polio- 
myelitis, 537, 540 
Nettle-rash, 570. See also Urticaria. 
Nettleship on hemophilia, 411 
Neuralgia, intercostal, counterirritants 

in, 776 
Neurasthenia, 498 
Neuritis, multiple, 542 
after diphtheria, 542 

treatment, 545 
convalescence in, 545 
diagnosis, 544 

diphtheria after, gavage in, 546 
distribution of lesion, 543 
drugs in, 544 
etiology, 542 
pathology, 543 
prognosis, 544 
sensory effects, 543 
symptoms, 543 
treatment, 544 
Neurotic eczema, 593 
Neutrophiles, polymorphonuclear, 395 
Nevus, 598. See also Ncbvus. 
New York City experiments in preven- 
tion of intestinal diseases of 
summer, 217 



New York County Medical Society, 

Milk Commission of, 51 
New-born infant, 17 

baskets for early exercises, 44 

bathing, 20 

beginning of feehng in, 43 

beginning of memory in, 43 

blood in, 394 

congenitally weak, 140 

constipation in, 238 

crying of, 44 

cutaneous sensation in, 42 

diseases of, 140 

feeding, 18 

fresh air for, 19 

hearing in, 42 

jaundice in, 143-145 

mammary abscess in, 155 

mastitis in, 155 

mental development, 42 

necessity of method in manage- 
ment of, 138 

nutrition and growth, 17 

environment as factor, 17 

heredity as factor, 17 

work and stress as factors, 20 

organic sensation in, 42 

physical development, 42 

powder for, 569 

premature, 140. See also Pre- 
mature infant. 

selection and preparation of food, 
19 

sepsis in, 146. See also Sepsis in 
new-horn. 

sight in, 42 

sleep required, 45 

smell in, 42 

stools of, 46. See also Stools. 

taste in, 42 

tetanus in, 156 

thirst-hunger in, 42 

umbihcal granuloma in, 154 

umbUical polyp in, 154 

vomiting in, management, 185 
lavage in, 185 

weighing, 39 

weight, 38 
hemorrhagic diseases of, 157 
New-growths of kidney, 438 
NichoUs and Adami on pathology of 
typhoid, 658 

on rachitis, 118 



896 



INDEX 



Nicolaier on pellagra, 740 

on tetanus bacillus, 156 
Nicoll and Bovaird on weight of thy- 
mus, 423 
Nicoll on blood findings in scarlet 
fever, 401 

on scarlet fever, 643 
NicoUe and Pianese on splenomegaly, 

263 
Night feedings, 61 
Night-terrors, 471 
Nihilism, therapeutic, 771 
Nipples, 47 

care of, in maternal nursing, 31 

cracked, 34 

depressed, 35 

fissured, 34 
Nipple-shield, 31 
Nitroglycerin in bronchopneumonia, 340 

in lobar pneumonia, 330 
Nitrous oxid gas as anesthetic, 751 
Noguchi and Flexner on case of anterior 

poliomyelitis, 535 
Noguchi butyric-acid test for syphilis, 
705 

on complement-fixation test in syphi- 
lis, 705 

on Spirochseta pallida, 677 

luetin test in syphilis, 706 
Noma, 166 

Northrup on sclerema neonatorum, 145 
Nose, diseases of, 267 

saddle, in tardy hereditary syphilis, 
688 
Nursery, 36 

airing of, 37 

floor of, 36 

for delicate children, 127 

furniture of, 37 

heating of, 37 

maid, 38 

ventilation of, 37 
Nursing-bottle, 47 
Nursing in scarlet fever, 652 

maternal, 21. See also Maternal 
nursing. 

prolonged rachitis after, 116 
Nutrient enema, 83 

amount of nourishment, 85 
method of giving, 83 
nourishment not to be used, 84 

to be used, 86 
peptonized milk for, 68 



Nutrition and growth of new-born 
infant, 17. See also New-born 
infant, nutrition and growth. 
disorders of, 86 
Nutritional errors in artificial feeding, 
48 
in tardy hereditary syphilis, 687 

Oatmeal jelly, formula for, 70 
Obesity, 752 

treatment, 752 
Obstetric paralysis, 547 
Obstinate constipation, treatment, 244 

vomiting, gavage in, 791 
Obstruction, intestinal, 244 

laryngeal, 292 
Obstructive jaundice, 265 
O'Dwyer intubation set, 639, 640 

on intubation, 638 
Oidium albicans, 162 
Oil, castor, 782 

injections in constipation in bottle- 
fed, 241 

inunction in scarlet fever, 653 
in tetany, 497 
Oils, method of administration, 782 
Olivier on weight of thymus, 423 
Ophthalmo-reaction with tuberculin 

in tuberculosis, 702 
Opie on diabetes mellitus, 735 
Oppenheimer on blood-pressure, 401 
Oppenheim's disease, 153 
Opsonic index, 798 
Opsonins, 797 
Orchitis, 462 
Ord on cretinism, 729 
Organic heart murmurs, 370 

sensation in new-born infant, 42 
Orth on localization of lobar pneu- 
monia, 322 
Orthostatic albuminuria, 452 
Osgood and Lucas on acute poliomye- 

Utis, 537 
Osier on cretinism, 728 

onlithemia, 709 

on Naunyn's exercise in empyema, 
825 

on polycythemia in congenital cya- 
nosis, 401 
Osteomyelitis, staphylococcus vaccine 

in, 799 
Otitis, acute, 601 

bacteriology, 601 



INDEX 



897 



Otitis, acute, complications, 603 
course, 603 

delayed resolution in, 605 
diagnosis, 603 
earache in, 602 
etiology, 601 
fever in, 602 
prognosis, 603 
symptoms, 602 
treatment, 603 
operative, 604 
post-operative, 604 
types, 601 
as cause of elevation of temperature, 

749 
chronic, suppurative, 605 

treatment, 606 
in influenza, 674 
in lobar pneumonia, 325 
in measles, 621 
in scarlet fever, 648 
treatment, 654 
staphylococcus vaccine in, 799 
Otten on pneumococcus, 321 
Out-door treatment of marasmus, 89 
Out-of-doors, days for, 762 
Overfeeding, 110 

Oxygen in bronchopneumonia, 342 
Oxyuris vermicularis, 248 

Pacifier, use of, 478 

Pack, cool, 777 

in typhoid fever, 666 

Packs in scarlet fever, 653 

Paine and Poynton on bacteriology of 
chorea, 519 
on diplococcus in rheumatism, 710 

Pains, growing, 709 

Palpation in acute endocarditis, 379 
in bronchopneumonia, 334 
in diseases of heart, 370 
in lobar pneumonia, 327 
of chest, 303 
of lungs, 303 
of thymus gland, 424 

Palsies, cerebral, 513. See also Paraly- 
sis, cerebral. 

Paltauf on cause of death in status 
lymphaticus, 426 
on tetany, 493 

Pancreas, tuberculosis of, 364 

Papper and Landsteiner on acute polio- 
myelitis, 536 

57 



Paracelsus on chorea, 518 

on cretinism, 727 
Paralysis, cerebral, 513 

acquired form, 515-517 
birth form, 513-515 
prenatal form, 513 
Erb's, 547 
facial, 546 
infantile, 535. See also Pob'omye- 

litis, acute. 
obstetric, 547 
progressive bulbar, 527 
wasting, 526 
Paralytic ileus, 245 
treatment, 202 
Parameningococcus in cerebrospinal 

meningitis, 558 
Paraphimosis, 461 
Parasites, eosinophilia from, 399 
intestinal, 247 

as cause of convulsions, 484 
blood in infections by, 247 
Park and Krumwiede on bovine tuber- 
culosis, 691 
Park and Zingher on blood transfusion, 
787 
on Schick reaction, 628 
Park on intestinal diseases of summer, 

217 
Parotitis, 611-613 
Paroxysmal hemoglobinuria, 436 
Parrot on chondrodystrophia, 725 

on sclerema neonatorum, 145 
Passive exercises for constipation, 844 

in anterior poliomyelitis, 842 
Pasteurization of milk, 74 

advantages and value of, 75 
effect on assimilation, 77 
Pasteurizer, Freeman's, 75 
Pastia on acute poliomyelitis, 537 
Patellar reflex in cerebrospinal men- 
ingitis, 562 
Pavor diurnus, 470 

nocturnus, 471 
Payne and Poynton on bacteriology of 

acute endocarditis, 378 
Peabody and Draper on blood in acute 

poliomyeUtis, 536 
Peabody, Draper and Dochez on acute 

poliomyelitis, 398, 536, 538, 539, 541 
Pearce on icterus neonatorum, 144 
Pediculi capitis, 574 
Peliosis rheumatica, 713 



898 



INDEX 



Pellagra, 738 

Pemphigus neonatorum, 579 

Pen, exercise, 767 

Peptonized milk, 68 

Percentage gruel flours, formulas for, 70 

Percussion, 303 

of chest, 303 

of lungs, 303 
Perforation in typhoid fever, 660 
Peri-arthritis, acute, diagnosis, 757 

in lobar pneumonia, 325 
Pericarditis, 374 

bacteriology, 374 

diagnosis, 375 

in lobar pneumonia, 325 

in scarlet fever, 648 

pathology, 374 

percussion in, 376 

physical signs, 375 

prognosis, 376 

purulent type, treatment, 377 

symptoms, 375 

treatment, 376 
Pericardium, adherent, 393 
Periodic fever, 720 

as cause of elevation of tempera- 
ture, 749 

vomiting, 715. See also Cyclic vomit- 
ing. 
Periostitis in tardy hereditary syphilis, 

687, 688 
Peristaltic wave in pyloric stenosis, 189 

method of obtaining, 190 
Peritoneum, diseases of, 172 

sepsis of, in new-born, 146 

tuberculosis of, 364 

chronic, 695. See also Tubercu- 
lous peritonitis, chronic. 
Peritonitis, acute, appendicitis and, 

differentiation, 254 
general, 256 

as complication, 256 

in lobar pneumonia, 325 

leukocytosis in, 398 

tuberculous, chronic, 695. See also 
Tuberculous peritonitis, chronic. 
Peritonsillar abscess, 283 
Perlin on blood in new-born, 394 
Permanent teeth, 170 
Pernicious anemia, 408 
Persistent cough, 272 
Pertussis, 614. See also Whooping 
cough. 



Petechial fever, 557 

Peterson on mental development of 

newly born, 42-44 
Petit mal type of epilepsy, 532 
Pfaundler on anatomy of stomach in 
new-born, 172 
on capacity of stomach, 172 
on pyloric stenosis, 185, 187 
Pfeiffer on Bacillus influenzae, 670 
Phagocytic index, 798 
Pharyngeal tonsils, 279 
Pharyngitis, 274 

Phenacetin in typhoid fever, 665 
Phillipp on carcinoma, 751 
Phimosis, 460 

as cause of convulsions, 484 
Physical development of new-born 

infant, 42 
Pianese and NicoUe on splenomegaly, 

263 
Picking of finger-tips, 478 
Piersol on anatomy of pharyngeal 

tonsils, 279 
Pigeon-breast, 302 

in rachitis, 118, 119 
Pin-worms, 248 
Plasmodium malarise, 666 

species of, 667 
Platinger on leukocytosis in measles, 400 
Playfair on siphon drainage in em- 
pyema, 356 
Pleura, adherent, as cause of cough, 273 
Pleurisy, appendicitis and, differentia- 
tion, 254 
counterirritants in, 776 
dry, 349 

empyema and, differentiation, 354 
fibrinous acute, 349 
primary, 348 
rheumatic, 713 
secondary, 348 
aspiration in, 351 
auscultation in, 350 
bacteriology, 349 
diagnosis, 350 
etiology, 348 

exploratory puncture in, 35 
pathology, 349 
percussion in, 350 
symptoms, 349 
treatment, 350 
with effusion, treatment, 351 
serous, acute, 349 



INDEX 



Pleurisy, tuberculous, 349 

ultimate results of treatment, 348 

with effusion, 349 

with purulent' effusion, 351. See 

also Empyema. 
Pleuritic effusion in lobar pneumonia, 

327 
Pneumobacillus of Friedlander, 321 
Pneumococcus, 321 

infection of lungs, acute, 316 
Pneumonia, 320 

acute, appendicitis and, differentia- 
tion, 254 
catarrhal, 332. See also Broncho- 
pneumonia. 
central, 326 
climate in, 773 

empyema and, differentiation, 354 
hypostatic, 345 
interstitial, 342 

auscultation in, 343 

diagnosis, 343 

pathology, 342 

percussion in, 343 

prognosis, 344 

pulmonary tuberculosis and, differ- 
entiation, 343 

symptoms, 343 
leukocytosis in, 397 
lobar, 320 

abortive type, 323 

acidosis in, 325 

auscultation in, 326 

bacterial etiology, 321 

bowels in, 328 

bronchopneumonia and, differen- 
tiation, 336 

clothing in, 328 

cold air in, 328 

complications, 324 

consolidation of lungs in, 326 

counterirritation in, 328 

delayed crisis in, 324 

deUrium in, 324 

diagnosis, 326 
differential, 327 

diarrhea in,. 324 

duration of attack, 323 

empyema in, 325, 353 

etiology, 321 

fever in, treatment, 329 

gavage in, 331 

heart stimulants in, 329 



Pneumonia, lobar, hydrotherapy in, 329 

hypodermic stimulation in, 331 

localization of lesions, 322 

meningitis in, 325 

mustard plaster in, 328 

myocarditis in, 325 

otitis in, 325 

palpation in, 327 

pathology, 321 

percussion in, 326 

peri-arthritis in, 325 

pericarditis in, 325 

peritonitis in, 325 

physical signs, 326 

pleuritic effusion in, 327 

predisposition to, 321 

prognosis in, 326 

respiration in, 323 

sick-room in, 328 

specific medication in, 331 

stage of congestion in, 321 
of gray hepatization in, 321 
of red hepatization in, 321 
of resolution in, 322 

stupor in, 324 

symptoms, 322 
unfavorable, 324 

temperature in, 322 
low, 324 

treatment, 327 

tympanites in, 324 

vocal fremitus in, 327 

vomiting in, 324 
Pneumothorax, 345 
Poisoning, ivj^ 571 

rhus, 571 
Polioencephalitis, 539 
Poliomj'elitis, acute, 535 

abortive, 538 

age incidence, 538 

blood findings in, 536 

bulbar spinal, 538 

cerebral, 538 

cerebrospinal fluid in, 536 

communicabihty, 541 

course, 540 

electricity in, 541 

electric reactions in, 540 

etiolog\", 535 

exercises in, 542, 841 

fever in, 538 

human serum in, 541 

immunity in, 537 



900 



INDEX 



Poliomyelitis, acute, incubation period, 
538 
leukocytosis in, 536 
massage in, 542, 843 
nasal mucous membrane in trans- 
mission, 537 
orthopedic treatment, 542 
pathology, 535 
prognosis, 540 
quarantine in, 541 
seasonal influences, 538 
symptoms, 538 
transmission, 536 
treatment, 541 
type of cases, 537 
virus in, 537 
chronic anterior, 526 
leukocytosis in, 398 
scurvy and, differentiation, 114 
Pollen anaphylaxis in hay-fever, 301 

disease, 301 
Pollinosis, 301 

Polycythemia in congenital heart dis- 
ease, 401 
Polymorphonuclear neutrophiles, 395 
Polyneuritis, 542. See also Neuritis, 

multiple. 
Polyp, umbilical, 154 
Polyuria, 734 

Porak on chondrodystrophia, 725 
Porencephalus, 500 
Pork tape-worm, 249 
Port-wine stain, 598 
Position in bed, diagnostic value, 131 
Posthemiplegic chorea, 518 
Posture, bad, correct sitting to over- 
come, 812 
standing to overcome 
exercise in, 809 
lying in good position to correct, 

812 
shot-bag exercise in, 811 
static exercises for, 811 
walking movements for, 778 
effect of clothing on, 807 
in exercise, 806 
in school, 809 
in sleep, 808 
Potassium chlorate in stomatitis, 166 
dangers, 166 
iodid, 782 
Pott on tetany, 493 
Powder, toilet, formula for, 569 



Poynton and Paine on bacteriology of 
acute endocarditis, 378 
on bacteriology of chorea, 519 
on diplococcus in rheumatism, 710 
Poynton on citrate of soda in milk 

adaptation, 63 
Pratt on hemophilia, 413 
Precocious maturity, 456 

menstruation, 456 
Premature infant, artificial heat for, 140 
feeding of, 141 
fresh air for, 141 
prevention of infection, 141 
room temperature for, 141 
Prenatal form of cerebral paralysis, 513 
Prickly heat, 569 
Prizner and Lucas on measles, 620 
Proctitis, 261 
catarrhal, 261 
membranous, 261 
ulcerative, 261 
Progressive amyotrophy, 526, 530. See 
also Amyotrophy, progressive. 
bulbar paralysis, 527 
muscular atrophies, 526 
spinal muscular atrophy, 526. See 
also Muscular atrophy, progressive 
spinal. 
Prolapse of rectum and anus, 258 
Proprietary foods, 71 

addition of fresh cow's milk, 73 
beef, 73 
dried milk, 72 
Prosek on scarlet fever, 643 
Proteid as cause of constipation in 
bottle-fed, 240 
milk in gastro-enteric intoxication, 

201 
of modified cow's milk, 55 
Proteids of breast-milk, 32 

of cow's milk, 49 
Protein milk, 65 
Pseudoleukemic anemia of von Jaksch, 

406 
Pseudomembranous ileocolitis, 222 
Pseudomuscular hypertrophy, 530 

waddling gait in, 531 
Pseudoparalysis, syphilitic, 681 
Psoriasis, 597 
Ptoses of stomach in older children, 

177-180 
Pulmonary abscess, 360 
gangrene, 360 



INDEX 



901 



Pulmonary stenosis, 371 

tuberculosis, 361. See also Tuber- 
culosis^ -pulmonary. 
Pump, breast, 35 

Puncture, exploratory, in secondary 
pleurisy, 350 
lumbar, 566. See also Lumbar -punc- 
ture. 
reaction in tuberculosis, 701 
Purpura, 409 
lulminans, 409 
hemorrhagic, 409 
Henoch's, 409 
simple, 409 
Pus in urine, 436 

Pyelitis, 453. See also Pyelocijstitis. 
Pyelocystitis, 453 
age incidence, 453 
as cause of elevation of temperature, 

749 
diagnosis, 455 
duration, 455 

elevation of temperature in, 454 
etiology, 453 

injection of Bacillus coli in, 801 
sex in, 453 
symptoms, 454 
time required for cure, 456 
treatment, 455 
vaccine, 456 
Pyloric spasm, hypertrophic pyloric 
stenosis and, differentiation, 190 
treatment, medical, 193 
stenosis, 185 

age incidence, 185 
catheter feeding in, 193 
constipation in, 188 
diagnosis, 189 
diet in, 192 
etiology, 187 

hypertrophic combined, obstruc- 
tion and, differentiation, 191 
pathology, 187 
peristaltic wave in, 189 

method of obtaining, 190 
prognosis, 191 

in combined cases, 192 
in spasmodic cases, 192 
with palpable tumor, 191 
pyloric spasm and, differentiation, 

190 
rectal medication in, 193 
retention of food in, 188 



Pyloric stenosis, sex incidence, 186 

symptoms, 188 

treatment, 192 

tumor in, 190 

vomiting in, 188, 219 

weight loss in, 189 
Pyogenic infection as cause of chronic 

rhinitis, 269 
Pyonephrosis, 439 
Pyrexia in acute illness, 136 
Pyro mania, 498 
Pyuria, 436 

Quarantine in acute poliomyelitis, 541 

in diphtheria, 634 

in influenza, 676 

in measles, 624 

in scarlet fever, 649 

in varicella, 611 
Quest on spasmophilia, 489 
Quincke on icterus neonatorum, 144 
Quincke's needle for lumbar puncture, 

566 
Quinin, 783 
Quinsy, 283 
Quiserne on polycythemia, 401 

Rach on acute luetic meningitis, 706 
Rachford on cyclic vomiting, 715 
Rachitic chest, 302 

rosary, 118 
Rachitis, 115 

after first year, 116 

after prolonged nursing, 116 

age of incidence, 115 

as cause of convulsions, 483 

associated with other diseases, 117 

bone changes in, 118, 119 

cod-liver oil in, 121 

constitutional disorders in, 119 

craniotabes, 118, 119 

cretinism and, differentiation, 120 

deformities in, treatment, 122 

diagnosis, 119 

diet in, 120 

drugs in, 122 

etiology, 116 

Harrison's grooves in, 118 

hydrocephalus and, differentiation, 
120 

hygiene in, 121 

in breast-fed, 116 

in etiology of tetanus, 492 



902 



INDEX 



Rachitis, mongolianism and, differen- 
tiation, 120 
nutritional errors in etiology, 116 
pathology, 117 
pigeon-breast in, 118, 119 
prognosis, 120 
racial predisposition, 116 
theories of pathogenesis, 117 
treatment, 120 
R^les, 307 
moist, 307 
mucous, 307 
musical, 307 
sibilant, 307 
sonorous, 307 
squeaking, 307 
Ramsey on pyloric stenosis, 187 
Ramsted operation in pyloric stenoses, 

192 
Rarefied air apparatus in emphysema, 

829 
Rash in acute hereditary syphilis, 680 
in German measles, 624 
in measles, 621 
delayed, 625 
in varicella, 610 
Reaction. See Test. 
Reckzan on blood findings in scarlet 

fever, 400 
Record antitoxin syringe, 633 

history, 132 
Rectal feeding, 83 

amount of nourishment, 85 
in acute illness, 136 
method of giving, 83 
nourishment not to be used, 84 
to be used, 85 
injections in oxyuriasis, 248 
medication in laryngismus stridulus, 
488 
in pyloric stenosis, 193 
Rectum and anus, prolapse of, 258 
in children, 258 

inflammation of, 261. See also Proc- 
titis. 
Rectus, spastic right, in appendicitis, 

253 
Recurrent vomiting, 715. See also 

Cyclic vomiting. 
Red cells, 394 

hepatization in lobar pneumonia, 321 
Reduplication of esophagus, 171 
Reflex eczema, 593 



Regurgitation, aortic, heart murmur in, 
372 
mitral, heart murmur in, 371 
treatment, 391 
Regurgitant murmur, 370 
Resonance of chest, 303 

tympanitic, 304 
Respiration, artificial, in asphyxia neona- 
torum, 150 
in cerebrospinal meningitis, 560, 562 
in lobar pneumonia, 323 
Respiratory exercises in emphysema, 828 
murmur in bronchopneumonia, 333 
tract, diseases of, 267 
Restlessness in acute hereditary syphilis, 

679 
Retention of urine, 430 
Retropharyngeal abscess, acute, 275- 
277 
spasmodic croup and, differentia- 
tion, 288 
adenitis, 275 

spasmodic croup and, differentia- 
tion, 288 
Rheumatic fever, 721 
pleurisy, 713 
symptom-complex, 709 
Rheumatism, 709 
acute, 721 

articular, counterirritants in, 776 
age incidence, 710 
bathing in, 711 
chorea and, relation, 519 
diet in, 710 
drugs in, 711 
etiology, 710 
leukocytosis in, 398 
recurrent bronchitis in, 712 
scurvy and, differentiation, 114 
treatment, 710 
Rheumatoid arthritis, 724 
Rhinitis, acute, 267 
chronic, 269 

in acute hereditary syphilis, 679 
in adenoids, 294 

specific, acute rhinitis and, differen- 
tiation, 267 
Rhus poisoning, 571 
Ribbert on carcinoma, 751 
Rice-water, formula for, 70 
Rickets, 115. See also Rachitis 
fetal, 725 
scurvy, 112 



INDEX 



903 



Rieder on leukoc3^tes, 395 

Rilliet and Barthez on congenital 

laryngeal stridor, 491 
Ring-worm, 575 

of scalp, 576 

of tongue, 167 
Roentgen-ray examination in ptoses 
and dilatation of stomach in 
older children, 177 
in status lymphaticus, 427 

treatment of status lymphaticus, 428 
of tinea tonsurans, 578 
Rohn on percussion of thymus gland, 

427 
RoUeston on blood-pressure, 401 
in contagious diseases, 402 
Rollier on heliotherapy, 366 

treatment of surgical tuberculosis, 698 
Romanowitch on trichiniasis, 251 
Room, sick-, in acute illness, 134 

temperature for exercise, 803 
for premature infants, 141 
in acute illness, 134 
Rosary, rachitic, 118 
Rose and Mendel on creatin excretion 
in starvation, 663 

spots in typhoid, 659 
Rosenel on tuberculosis, 693 
Rosenstern on tetany, 493 
Rotch on age in cerebrospinal men- 
ingitis, 559 

on capacity of stomach, 172 
Rotheln, 624 

Round shoulders, exercises for, 817 
Round-worms, 247 
Roux on diphtheria, 626 
Rubbing of finger-tips, 478 
Rubella, 624 
Rudolf on coagulation time of blood, 

402 
Ruminations, 220 
Runyon on cyclic vomiting, 715 
Russell and Babcock on proteid change 

in centrifugal cream, 74 
Russell on antityphoid inoculation, 800 

on dietetics and food economics, 22 

on typhoid carriers, 657 

Sabbatini on tetany, 493 

Saber deformity in tardy hereditary 

syphilis, 687 
Sachs on amaurotic family idiocy, 507 

on cerebral paralysis, 514 



Sachs on Erb's paralysis, 548 
on Friedreich's ataxia, 549 
on hydrocephalus, 509, 512 
on hysteria, 498 
on microcephalus, 500 
on primary dystrophies, 530 
Saddle nose in tardy hereditary syphilis, 

688 
Sahli on blood coagulation in hemo- 

phiUa, 412 
Sainton on true dwarfism, 733 
Salicylate of soda, 781 
Salts, ammonium, 782 
Salvarsan in acute hereditary syphilis, 

683, 684 
Sanitarium treatment of tuberculosis, 

774 
Sappey on thymus in new-born, 423 
Sarcoma of brain, 502 
Satterthwaite's method of artificial 

respiration in emphysema, 828 
Sauerbeck on diabetes mellitus, 735 
Scabies, 572 
Scala on pellagra, 738 
Scales, baby, 41 
Scalp, ring-worm of, 576 
Scapulohumeral type of progressive 

amyotrophy, 530 
Scarlatina, 643. See also Scarlet fever. 
Scarlet fever, 643 
adenitis in, 648 

treatment, 654 
albuminuria in, 648 
arthritis in, 648 

treatment, 656 
bacteriology, 643 
bowels in, 652 
bronchopneumonia in, 648 
care of nose and throat in, 654 
clothing in, 651 
complications, 647 

treatment, 654 
contagion, 644 
control of fever in, 653 
desquamation in, 646 

second, 646 
diagnosis, 647 
diet in, 651 
diphtheria in, 648 
endocarditis in, 648 
etiology, 643 

gastro-intestinal symptoms in, 
659 



904 



INDEX 



Scarlet fever, German measles and, 
differentiation, 625 

heart involvement in treatment, 655 

history, 643 

incubation period, 645 

kidney of, 442 

laxatives in, 652 

leukocytosis in, 400 

membranous non-diphtheric an- 
gina in, 647 

milk diet in, 651 

mortality, 649 

myocarditis in, 648 

nephritis in, 648 

nephritis in, treatment, 655 

nursing in, 652 

oil inunction in, 653 

otitis in, 648 
treatment, 654 

packs in, 653 

pericarditis in, 648 

prophylaxis, 649 

quarantine in, 649 

quiet in, 652 

second attacks, 645 

second desquamation in, 646 

serum treatment, 652 

severity, 647 

sick-room in, 650 

stimulants in, 653 

strawberry tongue in, 647 

streptococcus vaccine in, 800 

surgical, 656 

susceptibility, 645 

symptomatology, 645 

transmission, 644 

treatment, 650 

tub-baths in, 653 

urine examination in, 651 
Schaffer on glandular fever, 419 
Schaudinn and Hoffmann on Spirochaeta 

palHda, 677 
Schick on serum disease, 708 
test in diphtheria, 627-630 
Schiff on blood in new-born, 394 

on cretinism, 727 
Schloss on idiosyncrasy to food, 79 
School in chorea, 521 
in habit spasm, 525 
posture in, 809 
Schools for training nursery maids, 38 
Schultze's method of artificial respira- 
tion in asphyxia neonatorum, 150 



Schultz's sign in tetany, 495 
Scipiades on blood in new-born, 394 
Scleredema, sclerema neonatorum and, 

differentiation, 145 
Sclerema neonatorum, 145 

scleroderma and, differentiation, 
145 
Sclerosis, amytrophic lateral, 526, 527 
Scoliosis, 820 

Adams position in, 822 

diagnosis, 821 

exercises for, 822 

key-note position in, 824 

treatment, 822 
Scorbutus, 111. See also Scurvy. 
Scrambled egg stools, 46 
Scraped beef, formula for, 70 
Scratch skin test in hay-fever, 302 
Scripture on tics, 524 
Scurvy, 111 

age of incidence, 112 

Alpine, 738 

diagnosis, differential, 114 

etiology, 112 

infantile, 112 

pathology, 112 

poliomyelitis and, differentiation, 114 

prognosis, 114 

rheumatisn and, differentiation, 114 

symptoms, 113 

syphilis and, differentiation, 114 

trauma and, differentiation, 114 

treatment, 114 
Scurvy-rickets, 112 
Seborrhea, 595 

capitis, 595 

intertrigo, 596 
Seborrheic eczema, 598 
Sedatives in convulsions, 486 
Sedgwick on strapping jaw in rumina- 
tion, 220 
Seguin on Fowler's solution in chorea, 

522 
Seibert on diet in typhoid, 662 

on lavage, 788 
Seligmtiller on tetany, 493 
Senile chorea, 518 
, Sensation in cerebral paralysis, 616 
Sepsis in new-born, 146 
Septic sore throat, 286 
Septicemia, general, staphylococcus 

vaccine in, 799 
Sergeant on blood-pressure, 401 



INDEX 



905 



Serous meningitis, 565 
Serum, Flexner's, in cerebrospinal men- 
ingitis, 563-565 

human, in acute poliomyelitis, 541 

treatment of hemorrhagic diseases of 
new-born, 160 
technic, 161 
of scarlet fever, 652 
Shaffer on pathology of amaurotic 

family idiocy, 508 
Sharpe on decompression convulsions, 
484 

on Erb's paralysis, 548 
Shennan on pathology of acute diffuse 
nephritis, 442 

on tuberculous meningitis, 553 
Shield, nipple-, 31 

vaccination, 761 
Shore on streptococcus vaccine in 

erysipelas, 800 
Shoulders, round, exercises for, 817 
Sibilant rales, 301 
Sick-room in acute illness, 134, 137 

in bronchopneumonia, 337 

in lobar pneumonia, 328 

in scarlet fever, 650 
Siegert on rickets, 115 
Sight in new-born infant, 42 
Sigmoid, long, 208 
Sinus thrombosis, 606 
Sinuses, diseases of, as cause of chronic 

rhinitis, 270 
Siphon drainage in empyema, 356 
advantages, 359 
technic, 357 
Skimmed milk mixtures, 57 
Skin, care of, in health, 568 

changes in tardy hereditary syphilis, 
686 

diseases of, 568 

in cerebrospinal meningitis, 560 

reactions, tuberculin, in infancy, 703 

sepsis of, in new-born, 146 

test in hay-fever, 302 
Skull, fracture of, depressed, cephal- 
hematoma and, differentiation, 143 
Sleep, 45 

for delicate children, 127 

inspection during, diagnosis by, 132 

posture in, 808 
Smell, sense of, in new-born infant, 42 
Smith and LeWald on position after 

feeding, 94 



Snuffles, 267 
Soda bath, 780 

Sodium bicarbonate in cyclic vomiting, 
718 
bromid in whooping-cough, 618 
citrate in milk adaptation, 63 
salicylate, 781 
in chorea, 521 
Solids of cow's milk, 49 
Solis-Cohen on leukocytosis in tuber- 
culosis, 398 
Sonorous rales, 307 
Soor, 162 

Sophian on serum treatment of cere- 
brospinal meningitis, 564 
Sore throat, septic, 286 
streptococcus, 280 
Southworth on excessive ammonia 

excretion, 100 
Spasm, habit, 524 
Spasmodic croup, 287 

antispasmodics in, 291 
calomel fumigations in, 290 
cold compresses in, 290 
diagnosis, differential, 288 
etiology, 287 
expectorants in, 289 
laryngismus stridulus and, differ- 
entiation, 288 
pathology, 287 

retropharyngeal abscess and, differ- 
entiation, 288 
adenitis and, differentiation, 288 
steam inhalations in, 290 
symptoms, 287 
treatment, 288 
Spasmophilia, 489 
Spasmus nutans, 472 
Specific gravity of blood in new-born, 
394 
parotitis, 611-613 
vaginitis, 466 
Speech, disturbance of, in cerebral 
paralysis, 517 
exercise for, in congenital ataxias, 
840 
Spencer on success in life, 22 
Spermatic cord, hydrocele of, 463 

encysted, 464 
Sphygmomanometer, Faught's, 401 
Spina-bifida, 501 

Spinal cord, malformations of, 499 
meningocele of, 501 



906 



INDEX 



Spinal muscular atrophy, progressive, 
526. See also Muscular atrophy, 
progressive spinal. 
Spine, lateral curvature of, 820. See 
also Scoliosis. 
tuberculosis of, diagnosis, 758 
Spirochseta pallida, 677 
Spleen, diseases of, 263 

in acute hereditary syphilis, 680 
in Hodgkin's disease, 414 
in leukemia, 408 
in tardy hereditary syphilis, 688 
in typhoid fever, 659 
tuberculosis of, 63 
Splenomegaly, 263 
Splenomyelogenous leukemia, 407 
Sponging, cold, in fever, 776 

in acute illness, 134 
Spratling on epilepsy, 531 
Sprue, 162 

Sputum in pulmonary tuberculosis, 
care of, 366 
methods of obtaining, 362 
Squeaking rales, 307 
St. Vitus' dance, 518. See also Chorea. 
Stadelmann on icterus neonatorum, 143 
Stain, port-wine, 598 
Stammering, 525 
Staphylococcus aureus, 332 
vaccine, 799 

in antrum disease, 799 
in furunculosis, 799 
in general septicemia, 799 
in local suppuration, 799 
in osteomyelitis, 799 
in styes, 799 
Starch and opium in acute ileocolitis, 226 
bath, 780 

digestion in young infants, 68 
Starch-feeding, 66 
Status lymphaticus, 424 

as cause of convulsions, 484 
cause of sudden death in, 426 
diagnosis, 427 
etiology, 425 
pathology, 424 

roentgen-ray examination, 427 
roentgen-ray treatment, 428 
thymus in, 424 
treatment, 428 
Steam inhalations in bronchitis, 312 
in broiichopneumonia, 338 
in spasmodic croup, 290 



Stenosis, aortic, murmur in, 372 
congenital, of esophagus, 171 
mitral, heart murmur in, 371 

treatment, 391 
of pylorus, 183. See also Pyloric 



pulmonary, 371 
Stenotic murmur, 370 
Sterilization of milk, 74 
Sterilizer, Arnold, 75 
Sternocleidomastoid, hematoma of, 752 

treatment, 752 
Stethoscope, 308 

Bowles, 309 
Stick reaction in tuberculosis, 701 
Stiles on uncinariasis, 247 
Still on polycythemia, 401 

on pyloric stenosis, 185, 187, 190 

on rheumatic complex, 709 
fever, 721 

on rheumatoid arthritis, 724 

on tuberculosis, 694 

on tuberculous peritonitis, 695 
Still's disease, 724 

treatment, 724 
Stilling on cretinism, 729 
Stimulant inhalations in acute spas- 
modic bronchitis, 319 
Stimulants, heart, in bronchopneu- 
monia, 340 
in chronic valvular disease, 392 
in lobar pneumonia, 329 

in acute enteric intoxication, 203 

in erysipelas, 584 
Stimulation, hypodermic, in lobar pneu- 
monia, 331 

in acute illness, 137 
Stoeltzner on tetany, 493 
Stomach, anatomy of, 172 

capacity, 172 

cough, 272 

dilatation of, chronic, 176 

digestion, 172 
duration of, 173 

dilatation of, in older children, 177- 
180 

diseases of, 172 

hemorrhage from, 182 

motility, 173 

ptoses of, in older children, 177-180 

tuberculosis of, 363 

ulceration of, 183 
Stomach-feeding, substitutes for, 81 



INDEX 



907 



Stomach-tube, 791 

Stomach-washing, 788. See also Lavage. 

Stomach, dilatation of, vomiting from, 

219 
Stomatitis, 163 

aphthous, 163 

bacteriology, 163 

catarrhal, 163 

drugs in, 165 

etiology, 163 

feeding in, 165 

mouth-washing in, 165 

mycotic, 162 

necrobiosis in, 164 

potassium chlorate in, 166 
dangers, 166 

prognosis, 165 

symptoms, 164 

treatment, 165 
of ulceration, 165 

types, 163 

ulcerative, 163 
Stone in bladder, 458 
Stools, bacilli in, in pulmonary tuber- 
culosis, 363 

blood in, 47 

breast fed, 46 

cow's milk, 46 

curds in, 47 

hard balls, 46 
constipated, 46 

mucus in, 47 

scrambled egg, 46 
Strait-jacket in eczema, 591 
Strauch on rumination, 220 
Strawberry tongue in scarlet fever, 647 
Streptococcus sore throat, 280 

vaccine, 799 

in erysipelas, 800 
in scarlet fever, 800 
Strickler on tinea tonsurans, 578 
Stridor, congenital laryngeal, 491 

in laryngismus stridulus, 487 
Strophanthus in bronchopneumonia, 
340 

in chronic valvular heart disease, 
393 

in lobar pneumonia, 330 
Strouse on diabetes mellitus, 735 
Stnimpell on acute poliomyelitis, 539 

on relation of chorea to rheumatism, 
519 
Strvchnin, 783 



Styes, staphylococcus vaccine in, 799 
Styles on diphtheria, 627 
Subcutaneous inoculation with tuber- 
culin in diagnosis of tuberculosis, 
701 
emphysema, 347 
Sugar of modified cow's milk, 56 
Summer clothing, 763 
instructions for, 763 
intestinal diseases of, prevention, 216 
resorts, 768 
second, feeding in, 105 
water to drink in, 763 
Suppositories in constipation in nurs- 

Hngs, 239 
Suppression of urine, 430 
Suspension of bacteria, 798 
Sydenham on chorea, 518 
Sylvester's method of artificial respira- 
tion in emphysema, 828 
in empyema, 825 
Symptomatic infantilism, 733 
SyphiHs, 677 
acquired, 685 
acute hereditary, 678 

acute epiphysitis in, 681 
arsenicals in, 684 
arsenobenzol in, 685 
convalescence in, 683 
diarsenol in, 685 
eosinophilia in, 399 
fissures in, 681 
hemorrhage in, 681 
liver in. 680 
mercury in, 682-684 
mucous patches in, 681 
nails in, 681 

neosalvarsan in, 684, 685 
rash in, 680 
restlessness in, 679 
rhinitis in, 679 
salvarsan in, 683, 684, 685 
spleen in, 680 
symptoms, 678 
treatment, 682 
later, 682 
as etiologic factor in hemorrhagic 

diseases of new-born, 158 
butyric-acid test for, 705 
complement-fixation test for, 705 
congenital, 678, 684. See also Syphi- 
lis, acute hereditary. 
scurvy and, differentiation, 114 



908 



INDEX 



Syphilis, tardy hereditary, 685 

blood-vessels in, 686 

bones in, 687, 688 

ear changes in, 686 

errors in nutrition in, 687 

eye changes in, 686, 688 

Hutchinson's teeth in, 688 

liver in, 688 

lymph-nodes in, 686, 688 

Meniere's disease in, 686 

mixed treatment, 689 

pathology, 686 

periostitis in, 687, 688 

respiratory mucous membrane 
in, 686 

saber deformity in, 687 

saddle nose in, 688 

skin clianges in, 686 

spleen in, 688 

symptoms, 687 

teeth in, 688 

treatment, 688 

viscera in, 686 
Wassermann test for, 704 
Syphilitic pseudoparalysis, 681 
Syringe, antitoxin, 633 
Syringomyelocele, 501 

Tabes dorsalis, Friedreich's disease 
and, differentiation, 549 

mesenterica, 694 
Tache cerebrale in cerebrospinal men- 
ingitis, 561 
Taenia elliptica, 249 

saginata, 249 

solium, 249 
Takasu on blood in new-born, 394 
Talipes planus, exercises for, 844-846 

massage in, 845 
Tannalbin in acute ileocolitis, 224 
Tape-worm, beef, 249 

fish, 249 

pork, 249 
Tape-worms, 249 
Tardy malnutrition, 100 

of syphilitic origin, 689 
Tartar emetic, 782 
Taste in new-born infant, 42 
Tay on amaurotic family idiocy, 507 
Teeth, 169 

care of, 169 

in tardy hereditary syphilis, 688 

permanent, 170 



Teething cough, 272 

Telangiectasis, 598. See also Ncevus. 

Temperature, 744 

elevation of, encysted empyema as 
cause, 749 
from active exercise, 747 
intestinal infection as cause, 749 
otitis as cause, 749 
periodic fever as cause, 749 
pyelitis as cause, 749 
tuberculosis as cause, 749 
typhoid fever as cause, 749 
unexplained, 749 
high, in acute illness, treatment, 136 
in cerebrospinal meningitis, 560, 562 
in intussusception, 234 
in lobar pneumonia, 322 
in measles, 621 
in varicella, 610 
low, in lobar pneumonia, 324 
normal, 744 

obscure elevation of, 747 
of room in acute illness, 134 
for premature infants, 141 
in exercise, 803 
Teniasis, 248 

Test, Schick, in diphtheria, 627-630 
butyric-acid, for syphilis, 705 
Noguchi's luetin, in syphilis, 706 
complement-fixation for syphilis, 705 
tuberculin, Calmette's, 703 

Detre's differential cutaneous, 702 
•Hamburger's, 701 
Moro inunction, 702 
skin, in infancy, 703 
von Pirquet's, 702 
Wassermann, for syphilis, 704 
Widal, in typhoid fever, 707 
Testicle, undescended, 462 

inguinal hernia and, differentiation, 
755 
Testut on weight of thymus, 423 
Tetanus antitoxin in tetanus neona- 
torum, 157 
bacillus, 156 

electric irritability in, 495 
neonatorum, 156 
rachitis in etiology, 492 
Tetany, 491 

accoucheur hand in, 494 
as cause of convulsions, 485 
age incidence, 492 
bath in, 498 



INDEX 



909 



Tetany, Chvostek's sign in, 495 

climate in, 497 

diagnosis, 495 

duration, 495 

etiology, 492 

muscle irritability in, 494 

oil inunctions in, 497 

prognosis, 496 

proteid diet in, 497 

Schultz's sign in, 495 

symptoms, 494 

tonics in, 497 

treatment, 496 

Trousseau's sign in, 495 
Thayer on malaria, 667 
Therapeutics, gymnastic, 803. See also 

Exercise. 
Therapeutic measures, 771 

nihihsm, 771 

value of climate, 773 
Thermometer, bath, 779 
Thiemich's lip sign in spasmophilia, 490 
Thiemich on tetany, 493 
Thirst-hunger in new-born infant, 42 
Thomas strait-jacket in eczema, 591 
Thompson and Deaderick on pellagra, 

740 
Thompson on exercise, 803 
Thomson on hemorrhagic diseases of 
new-born, 159 

on pyelocystitis, 454 
Thomson's theory of pyloric stenosis, 

187 
Thread-worm, 248 
Thrill in diseases of heart, 372 
Thoracic breathing, 813 
Throat, diseases of, 267 

examination, 271 

irrigation of, 278 

in peritonsillar abscess, 284 
indications, 278 
technic, 278 

septic sore, 286 

sore, streptococcus, 280 
Thrombosis, sinus, 606 
Thrush, 162 
Thumb-sucking, 478 
Thymol in uncinariasis, 251 
Thymu. gland, 423 

enlargement of, 424. See also 
Status lymphaticus. 
Thyroid treatment in cretinism, 731- 

733 



Tic, 524 

Tinea circinata, 575 

tonsurans, 576 
Tongue, geographic, 167 

ringworm of, 167 
Tonsillar diphtheria, tonsillitis and, 

differentiation, 281 
Tonsillitis, 280 

follicular, acute, 280 
Tonsil, abdominal, 252 
Tonsils, anatomy, 279 

and adenoids, radical removal, 298 
diseased, permanently, 297 

necessity for operative inter- 
ference, 297 
enlarged, adenoids associated with, 

296 
faucial, 279 

hypertrophy of, chronic, 297 
lingual, 279 
pharyngeal, 279 
radical removal of, 298 
tubal, 279 
Top-milk methods of milk modifica- 
tion, 59 
formulas, 60 
Tracheal cough, 273 
Transfusion, blood, 786 

in secondary anemia, 404 
indications for, 786 
prevention of hemolysis in, 786 
Transitional cells, 395 
Transmissible diseases, 608 
Trauma, scurvy and, differentiation, 

114 
Traumatic eczema, treatment, 589 

laryngitis, 291 
Traveling, milk for, 69 
Treponema palUdum, 677 
Trichina spiralis, 251 
Trichinella spiralis, 251 
Trichiniasis, 251 
Trousseau's sign in spasmophilia, 490 

in tetany, 495 
Tubal tonsils, 279 
Tub-baths for fever, 779 

in scarlet fever, 653 
Tuberculin in diagnosis of tuberculosis, 
701 
cutaneous inoculation, 702 
eye inoculation, 703 
subcutaneous inoculation, 701 
skin reactions in infancy, 704 



910 



INDEX 



Tuberculin test, Calmette's, 703 

Detre's differential cutaneous, 702 

Hamburger's, 701 

Moro inunction, 702 

skin, in infancy, 703 

von Pirquet's, 702 
treatment of tuberculosis, 801 
Tuberculosis, 691 
abdominal, 694 
acute miliary, typhoid fever and, 

differentiation, 661 
as cause of cough, 273 

of elevation of temperature, 749 
avenues of entrance of bacillus, 

692 
bovine, 691 
climate in, 774 
from milk infection, 693 
joint, diagnosis, 758 
leukocytosis in, 398 
of cervical lymph-nodes, 420 
of hip, diagnosis, 758 
of kidney, 438 
of mesenteric gland, 694 
of spine, diagnosis, 758 
predisposing causes, 692 
pulmonary, 361 

associated lesions, 363 

bacilli in stool, 363 

bronchitis and, differentiation, 314 

climate in, 364 

diagnosis, 362 

diet in, 364 

empyema and, differentiation, 355 

heart involvement in, 363 

heliotherapy in, 366 

hygiene in, 365 

interstitial pneumonia and, differ- 
entiation, 343 

intestinal involvement in, 364 

kidney involvement in, 364 

liver involvement in, 363 

pathology, 361 

prognosis, 363 

spleen involvement in, 363 

sputum in, care of, 366 
methods of obtaining, 362 

symptoms, 361 

tonics in, 365 

treatment, 364 
relative frequency in different sites, 

693 
sanitarium treatment, 774 



Tuberculosis, stomach involvement in, 
363 
surgical, heliotherapy in, 698 

RoUier's treatment, 698 
tuberculin in diagnosis, 701 
cutaneous inoculation, 702 
eye inoculation, 703 
subcutaneous inoculation, 701 
treatment, 801 
types of infections, 691 
Tuberculous adenitis, 420 

caries of cervical vertebra, 278 
meningitis, 553. See also Meningitis, 

tuberculous. 
peritonitis, chronic, 695 
age incidence, 696 
ascitic type, 696 
diagnosis, 697 
etiology, 695 
heliotherapy in, 698 
pathology, 695 
plastic type, 696 
prognosis, 697 
symptoms, 696 
treatment, surgical, 698 
types of lesions, 696 
pleurisy, 349 
Tumors of brain, 502. See also Brain 

tumors. 
Tunica vaginalis, hydrocele of, 464 
Tunnicliff and Weaver on necrobiosis, 
166 
on streptococcus vaccine in scarlet 
fever, 800 
Turbinated bones, hypertrophy of, as 

cause of chronic rhinitis, 269 
Turpentine in bronchopneumonia, 338 
Tussis infantum, 614 

perennis, 614 
Tympanites in lobar pneumonia, 324 
Tympanitic dulness of chest, 304 

resonance of chest, 304 
Typhoid bacillus, 657 

dead, inoculation of, 800 
fever, 657 

acute miliary tuberculosis and, 

differentiation, 661 
as cause of temperature elevation, 

749 
bacteriology, 657 
bathing in, 661, 666 
care of bowels in, 664 
of discharges in, 661 



INDEX 



911 



Typhoid fever, carriers, 657 

complications, 660 

control of fever in, 665 

cool pack in, 666 

diagnosis, differential, 660 

diagnostic signs, 660 

diarrhea in, treatment, 664 

drugs in, 664 

duration of immunity conveyed, 
659 

empyema and, differentiation, 355 

feeding in, 661 

heart stimulants in, 665 

hemorrhage in, treatment, 666 

intestinal hemorrhage in, 660 
lavage in, 666 

leukocytosis in, 398 

milk in, 663 

mortahty, 661 

mouth toilet in, 661 

nervous symptoms, 659 

pathology, 658 

perforation in, 660 
treatment, 666 

phenacetin in, 665 

pulse in, 659 

rose spots in, 659 

spleen in, 659 

symptoms, 658 

temperature in, 660 

transmission, 658 

treatment, 661 

vaccination against, 658 
advisability, 659 

Widal reaction in, 707 
Typhus syncopahs, 557 

Ulcer, duodenal, 184 
Ulceration at angle of mouth, 168 

of stomach, 183 
treatment, 165, 183 
Ulcerative proctitis, 261 

stomatitis, 163 
Ulcus, Egyptacum, 625 

Syracum, 625 
Umbihcal cord, care of stump, 41 
hernia of, 753 

granuloma, 154 

hernia, 753 

congenital, 754 

polyp, 154 
Umbihcus, sepsis of, in new-bom, 146 
Uncinaria Americana, 250 



Uncinariasis, 250 

Underwood's disease, 145 

Undescended testicle, 462 

Unger and Koplik on Schick test, 

628 
Unger on blood transfusion, 786 
Unpalatable drugs, 781 
Urea excretion in acute diffuse nephritis, 

448 
Uremia, convulsions in, 484 

in acute diffuse nephritis, 444 
treatment, 448 
Urethra, atresia of, 469 
Urination, continence estabhshed, 430 

difficult, 430 

normal variations of, 429 

painful, 430 
Urine, 429 

blood in, 436 

examination, in acute diffuse neph- 
ritis, 444 
in scarlet fever, 651 
in acute illness, 135 

in acute diffuse nephritis, 443 

in diabetes mellitus, 736 

in gastro-enteric intoxication, 195 

incontinence of, 432-434 

method of collecting, 430 

observations on, 429 

pus in, 436 

retention, 430 

suppression, 430 
Urogenital system, diseases of, 429 
Urticaria, 570 

after injection of diphtheria anti- 
toxin, 635 

giant, 570 

Vaccination, 760 

after-treatment, 760 

against typhoid fever, 658 

complications, 761 

constitutional disturbances from, 761 

in typhoid, advisabihty, 659 

local applications, 761 

method, 760 

shield, 761 

site, 760 
Vaccine, gonococcus, 800 

meningococcus, 800 

preparation of, 798 

staphylococcus, 799. See also Staphy- 
lococcus vaccine. 



912 



INDEX 



Vaccine, streptococcus, 799. See also 
Streptococcus vaccine. 
treatment, 797 

fundamental principles, 797 
in gonorrheal vulvovaginitis, 469 
of cerebrospinal meningitis, 565 
of pyelocystitis, 456 
of whooping-cough, 617 
Vagina, atresia of, 469 
Vaginal hydrocele, common, 464 
Vaginitis, specific, 466 
Valvular disease, chronic, of heart, 389 
constructive medication in, 

392 
diagnosis, 390 
diet in, 391 
digitalis in, 392 
drugs in, 391 
etiology, 389 
heart rest in, 392 

stimulants in, 392 
prognosis, 390 
strophanthus in, 393 
symptomatology, 389 
treatment, 390 
heart murmurs, 370 
Van Cott and Lind on trichiniasis, 251 
Vapor treatment in measles, 624 

of influenza, 677 
Vaquez on polycythemia, 401 
Varicella, 609-611 
Veeder on duodenal ulcer, 184 

on mercury in syphilis, 682 
Venous heart murmurs, 373 
Ventilation in acute illness, 134 

of nursery, 37 
Ventral hernia, 756 

Vermiform appendix, anatomy of, 252 
Vertebra, cervical, tuberculous caries 

of, 278 
Vesical calculus, 458 
Vesicular breathing, 304, 305 
distant, 305 
exaggerated, 305 
Vincent's angina, 285 
Virchow on cretinism, 729 
on hemophilia, 412 
on nsevus, 598 
on necrobiosis, 164 
on ossification of cranial bones, 500 
Virus in acute poliomyelitis, 537 
Viscera in tardy hereditary syphilis, 686 
Vocal fremitus in lobar pneumonia, 327 



Voegtlin and McCallum on spasmo- 
philia, 494 
on tetany, 494 
Vomiting, 219 

cyclic, 715. See also Cyclic vomiting. 
from dilatation of stomach, 219 
from pyloric stenosis, 219 
in icterus, 265 

' in infants, management of, 185 
in lobar pneumonia, 324 
in pyloric stenosis, 188 
obstinate, gavage in, 791 
of blood, 182 

periodic, 715. See also Cyclic vomit- 
ing. 
appendicitis and, differentiation, 
254 
persistent, in acute gastric indiges- 
tion, treatment, 175 
recurrent, 715. See also Cyclic vomit- 
ing. 
von Behring on bovine tuberculosis, 693 
von Eiselsberg on cretinism, 727 
von Etlinger on hemophilia, 413 
von Hecker and Buhl on hemorrhagic 

diseases of new-born, 157, 159 
von Jaksch, pseudoleukemic anemia of, 

406 
von Mering on diabetes mellitus, 735 
von Pirquet on serum disease, 708 
von Pirquet's tuberculin test in tuber- 
culosis, 702 
von Weisner and Leiner on acute polio- 
myelitis, 537 
Vulvovaginitis, gonorrheal, 466 
simple, 465 

Waddling gait in pseudomuscular 
hypertrophy, 531 

Walbach on pyloric stenosis, 188 

Walking movements for bad posture, 
778 
up and down stairs in congenital 
ataxias, 839 

Warm packs in acute infective menin- 
gitis, 552 

Washing, stomach, 788. See also 
Lavage. 

Wassermann test for syphilis, 704 
in tardy hereditary syphilis, 689 

Wasting palsy, 526 

Water, drinking of, in acute illness, 134 
for nursing mother, 26 



INDEX 



913 



Water to drink in summer, 763 
Water-pressure reduction of intussus- 
ception, 235 
Watt on whooping-cough, 614 
Weakened breathing, 306 
Weaning, care of breasts during, 30 
Weaver and Tunnicliff on cancrum oris, 

166 
Weaver on scarlet fever, 643 
Webb on heUotherapy, 366 
Webber on cerebrospinal meningitis, 

557 
Weighing infants, 39, 124 
Weight loss in pyloric stenosis, 189 

of new-born infant, 38 
Welch's treatment of hemorrhagic dis- 
eases of new-born, 160 
technic, 161 
Werdnig and Hoffmann on progressive 

amyotrophy, 526 
West on glandular fever, 419 

on tetany, 493 
Wet-brain in gastro-enteric intoxica- 
tion, 195 
Wet-nurse, 33 

in gastro-enteric intoxication, 199 

in marasmus, 88 

selection of, 33 
Wheat jelly, formula for, 70 
Whey-feeding, 64 

in malnutrition, 94 
Whey, formula for, 71 
Whistler on rickets, 115 
W^hooping-cough, 614 

bacteriology, 614 

climate in, 773 

complications, 616 

diagnosis, 616 

fresh air in, 619 

history, 614 

incubation, 616 

infective period, 615 

interrupted medication in, 618 

leukocytosis in, 399 

pathology, 615 

prognosis, 617 

sedatives in, 618 

susceptibility, 615 

symptoms, 616 

transmission, 615 

treatment, 617 



Wickman on acute poliomyelitis, 539, 

540 
Widal on salt-free diet in acute neph- 
ritis, 446 
reaction in typhoid fever, 707 
Wilcox and Miller on pyloric stenosis, 
187 
on tetan3% 492 
Williams on scarlet fever, 643 
Winckel on hemorrhagic diseases of 

new-born, 158 
Winckel's disease, 158 
Window-board, 138 
Wolff -Eisner tuberculin reaction in 

tuberculosis, 703 
W'ollstein and Amoss on serum treat- 
ment of cerebrospinal meningitis, 
564 
Woilstein and Jacobi on fetal tubercu- 
losis, 693 
Wollstein'on influenza, 671 
on lymphatic leukemia, 407 
on mumps, 611 
on whooping-cough, 614 
Wood on blood in congenital heart dis- 
ease, 388 
on transmission of epilepsy, 531 
Work and stress as factors in nutrition 

and growth of new-born infant, 20 
Wright and Douglas on opsonins, 

797 
Wright on blood coagulation in hemo- 
phiha, 412 
on scurvy, 112 

on staphylococcus vaccine in general 
septicemia, 799 
Wyeth on hypospadias, 464 

X-RAY. See Roentgen-ray. 

Yerberzine, 783 

in malaria, 669 
Yersin on diphtheria, 626 
Young on trichiniasis, 251 

Zelenski-Cybulski on infantile blood, 

396 
Zingher and Park on blood transfusion, 
787 
on Schick reaction, 628 
Zwiefel on starch digestion, 68 



58 



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Carman & Miller's X-ray 
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Rontgenology of the Qastro=intestinal Tract. By Russell D. 
Carman, M. D., Head of Section on Rontgenology, and Albert Mil- 
ler, A. B., M. D., Second Assistant in Section on Rontgenology, 
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COMPREHENSIVE IN DETAIL 

This work takes up the diagnosis of disease of the alimentary tract, following 
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DIAGNOSIS AND TREATMENT 



Cabot's Works on Diagnosis 

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The sy7tipto?n-groups in Volume 1 (Third Edition— January, 1915) are: Headache, gen- 
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coma, convulsions, weakness, cough, vomiting, hematuria, dyspnea, jaundice, and nervous- 
ness — 21 symptoms and 385 cases. 

Volume II (December, 1914) : Abdominal and other tumors, vertigo, diarrhea, dyspepsia, 
hematemesis, enlarged glands, blood in stools, swelling of face, hemoptysis, edema of legs^ 
frequent micturition and polyuria, fainting, hoarseness, pallor, swelling of arm, delirium, pal- 
pitation and arhythmia, tremor, ascites and abdominal enlargement — a total of 19 symptoms 
and 317 instructive cases. 



Morrow's Diagnostic and 
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Diagnostic and Therapeutic Technic. By Albert S. Morrow, 
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measures employed in the diagnosis and treatment of diseases of special regions or 
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Journal American Medical Association 

" The procedures described are those which practitioners may at some time be called 
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Musser and Kelly on 
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Thomson's Clinical Medicine 

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Ward's Bedside Hematology 

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Faught's Blood-Pressure 

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Smith's What to Eat and Why 

What to Eat and Why. By G. Carroll Smith, M.D., Boston. 

1 2mO of 377 pages. Cloth, $2.75 net. Published September, 1915 

SECOND EDITION 

With this book you no longer need send your patients to a specialist to be 
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Anders ^ Boston's Medical Diag(nosis 

(Published July, 1914) 

A Text-Book of Medical Diagnosis. By James M. Anders, M. D., 
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Anders' 
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DaCosta's Physical Diag^nosis 

Physical Diagnosis. By John C. DaCosta, Jr., M. D., Associate 
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THIRD EDITION -published November. 1915 
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Dr. Henry L. Eisner, Professor of Medicine at Syracuse University. 

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Phy,sical Diagnosis. Part I : By George William Norris, A. B., 
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here the application of the four methods to your daily clinical work. 

Priedenwaid and Ruhrah on Diet 

Diet in Health and Disease. By Julius Friedenwald, M. D., 
Professor of Diseases of the Stomach, and John Ruhrah, M. D., Pro- 
fessor of Diseases of Children, College of Physicians and Surgeons, 
Baltimore. Octavo of 857 pages. Published juiy, 1913. Cloth, $/\..oo net. 

FOURTH EDITION 

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Carter's Diet Lists 

Diet Lists of the Presbyterian Hospital of New York City. 
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Kemp on Stomach, 
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Diseases of the Stomach, Intestines, and Pancreas. By Robert 
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Tlie Therapeutic Gazette 

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Gant on Diarrheas 

Diarrheal, Inflammatory, Obstructive, and Parasitic Diseases of 
the Ga3tro=intestinal Tract. By Samuel G. Gant, M. D., LL.D., 

Professor of Diseases of Sigmoid Flexure, Colon, Rectum, and Anus, 
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Gant on Constipation and Obstruction 

This work is medical, non-medical (mechanical), and surgical, the latter really 
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Octavo of 575 pages, with 250 illustrations. By Samuel G. Gant, M. D. Clot?i, ^6.00 net. 



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SoUmann's Pharmacology 

A Manual of Pharmacology : Its Applications to Therapeutics 
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JUST OUT— BASED ON THE 1916 U. S. PHARMACOPOEIA 

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sideration. All the new remedies are included, with detailed instructions for their 
use : Vaccines, serums, salvarsan, neosalvarsan, pituitary extract, emetin — all 
those new remedies of the Pharmacopoeia being so extensively discussed and em- 
ployed. Every worthwhile development in the field of pharmacology is included. 

LABORATORY GUIDES, ^he exercises in this Laboratory Guide 

present no difficulty in technic, and re- 
quire little help from the instructor. They teach you how to teach yourself. Special 
stress is laid on facts with direct practical bearing. The experiments on animals 
are arranged in groups to illustrate various types or phenomena, to bring out the 
similarities and differences of the response of organs to pharmacologic agents, 
rather than to individual drugs. This arrangement articulates better with the 
student's experience in physiology and pathology. 

A Laboratory Guide in Pharmacology. By Torald Sollmann, M. D. Octavo of 355 pages, illustrated. 
Cloth, $2.50 net. 



Amy's Pharmacy 

Principles of Pharmacy. By Henry V. Arny, Ph. D.. Professor 
of Chemistry, New York College of Pharmacy. Octavo of 1056 pages, 
with 246 illustrations. Cloth, $5.50 net; Half Morocco, $7.00 net. 

SECOND EDITION— published March, 1917 

Professor Arny divides his book into seven parts : The first part deals with phar- 
maceutic processes, a striking feature being the clear discussion of the arithuietic 
of pharmacy ; the second, with galenic preparations of the Pharmacopoeia and those 
unofficial preparations of proved value; the third, with the inorganic chemicals, 
including the theories of chemistry; the fourth discusses the organic chemicals; 
the fifth is devoted to chemical testing, presenting a systematic grouping of all 
the tests of the Pharmacopma; the sixth discusses the prescription from the time 
it is written until it is dispensed; the seventh is devoted to laboratory work, with 
exercises in equation writing and chemical arithmetic . 

George Reimann, Ph. G., Secretary New York State Board of Pharmacy 

" I would say that the book is certainly a great help to the student, and I think it ought to 
be in the hands of every person who is contemplating the study of pharmacy." 



THERAPEUTICS AND EXERCISE ii 

Bastedo's Materia Medica 

Pharmacology, Therapeutics, Prescription Writing 

Materia Medica, Pharmacology, Therapeutics, and Prescription 
Writing. By W. A. Bastedo, Ph. D., M. D., Associate in Pharma- 
cology and Therapeutics at Columbia University, New York. Octavo 

of 602 pages, illustrated. New (2dj Edition ready soon 

THREE PRINTINGS IN SIX MONTHS 

Dr. Bastedo' s discussion of his subject is very complete. As an ilhistration, 
take the pharmacologic action of the drug. It gives you the antiseptic action, the 
local action on the skin, mucous membranes, and the alimentary tract ; where the 
drug is obsorbed, if at all — and how rapidly. It gives you the systemic action on the 
circulatory organs, respiratory organs, nervous system, and sense organs. It tells 
you how the drug is changed in the body. It gives you the route ol elimination 
and in what form. It gives you the action on the kidneys, bladder, urethra, skin, 
bowels, lungs, and mammary glands during ehmination. It gives you the after- 
effects. It gives you the unexpected — the unusual — effects. It gives you the 
tolerance — habit formation. Could any discussion be more complete, more 
thorough ? 

Boston Medical and Surgical Journal 

" Its aim throughout is therapeutic and practical, rather than theoretic and pharmacologic. 
The text is illustrated with sixty well-chosen plates and cuts. It should prove a useful con- 
tribution to the text-book literature on these subjects." 



McKenzie on Exercise in 
Education and Medicine 

Exercise in Education and Medicine. By R. Tait McKenzie, B. A^ 

M. D., Professor of Physical Education and Director of the Department, 

University of Pennsylvania. Octavo of 585 pages, with 478 original 

illustrations. Cloth, $4.00 net. 

SECOND EDITION— published June. 1915 

D, A. Sarg[eant, M. D., Director of Hemenway Gymnasium, Harvard Uni'^ersity. 

" It cannot fail to be helpful to practitioners in medicine. The classification of athletic 
games and exercises in tabular form for different ages, sexes, and occupations is the work of an 
expert. It should be in the hands of every physical educator and medical practitioner." 

Bonney's Tuberculosis second Edition 

Tuberculosis. By Sherman G. Bonnev, M. D., Professor of Medi- 
cine, Denver and Gross College of Medicine. Octavo of 955 pages, with 
243 illustrations. Cloth, $7.00 net ; Half Morocco, ^8.50 net. 
Maryland Medical Journal 

" Dr. Bonney's book is one of the best and most exact works on tuberculosis, in all its 
aspects, that has yet been published." Published May, 1910 



12 SAUNDERS' BOOKS ON 

Garrison's 
History of Medicine 

History of Medicine. With Medical Chronology, Bibliographic 
Data, and Test Questions. By Fielding H. Garrison, M. D., Prin- 
cipal Assistant Librarian, Surgeon-General's Office, Washington, D. C. 
Cloth, ^6.00 net ; Half Morocco, $7.50 net. Published December, 1913 

REPRINTED IN THREE MONTHS— THE BAEDEKER OF MEDICAL HISTORY 

The work begins with ancient and primitive medicine, and carries you in a 
most interesting and instructive way on through Egyptian medicine, Sumerian 
and Oriental medicine, Greek medicine, the Byzantine period ; the Mohammedan 
and Jewi-sh periods, the Medieval period, the period of the Renaissance, the Re- 
vival of learning and the Reformation ; the Seventeenth Century (the age of indi- 
vidual scientific endeavor), the Eighteenth Century (the age of theories and 
systems), the Nineteenth Century (the beginning of organized advancement of 
science), the Twentieth Century (the beginning of organized preventive medicine). 
You get all the important facts in medical history; a biographic dictionary; an 
album of medical portraits; and a complete medical chronology. 

Stevens' Therapeutics Fifth Edition. September, 1909 

A Text-Book of Modern Materia Medica and Therapeutics. 
By A. A. Stevens, A. M., M. D., Lecturer on Physical Diagnosis in 
the University of Pennsylvania. Octavo of 675 pages. Cloth, ^3.50 net. 

Dr. Stevens' Therapeutics is one of the most successful works on the 
subject ever published. In this new edition the work has undergone a 
very thorough revision, and now represents the very latest advances. 

The Medical Record, New York 

" Among the numerous treatises on this most important branch of medical practice, 
this by Dr. Stevens has ranked with the best." 

Butler's Materia Medica sixth Edition 

A Text-Book of Materia Medica, Therapeutics, and Pharma- 
cology. By George F. Butler, Ph. G., M. D., Professor and Head 
of the Department of Therapeutics and Professor of Preventive and 
Clinical Medicine, Chicago College of Medicine and Surgery, Medical 
Department Valpariso University. Octavo of 702 pages, illustrated. 
Cloth, $4.00 net; Half Morocco, ^5.50 net. Published June, 1908 

For this sixth edition Dr. Butler has entirely remodeled his work, a great 
part having been rewritten. All obsolete matter has been eliminated, and 
special attention has been given to the toxicologic and therapeutic effects 
of the newer compounds. 

Medical Record, New York 

•'Nothing has been omitted by the author which, in his judgment, would add to the 
completeness of the text." 



THERAPEUTICS AND MATERIA MEDIC A 13 

Tousey's Medical Electricity 
Rontgen Rays, &nd Radium 

Medical Electricity, Rontgen Rays, and Radium. By Sinclair 
TousEY, M. D., Consulting Surgeon to St. Bartholomew's Hospital, 
New York. Octavo of 1219 pages, with 801 illustrations, ig in colors. 
Cloth, $7.50 net; Half Morocco, 39.00 net. Published February, 1915 

SECOND EDITION. RESET 

The revision for this edition was extremely heavy ; new matter has increased the size 
of the book by some 100 pages. Aboui 50 new ilkistrations have been added. The new 
matter added includes : Diathermy, sinusoidal currents, radiography with intensifying 
screens, rontgenotherapy, the Coolidge and similar Rontgen tubes and the author's method 
of dosage, and radium therapy are noted. The book has been enriched by including several 
of Machado's tabular classifications of electric methods, effects, and uses. 

Throughout the entire work everything concerning electricity, .r-rays, and radium in 
medicine, as well as phototherapy, is explained in detail — nothing is omitted. It tells you 
how to equip your office, and, more than that, how to use your apparatus, explaining away 
all difficulties. It tells you just how to apply these measures in the treatment of disease. 
The chapters on dental radiograpJiy are particularly valuable to those interested in dental 
work. 



Deaderick £^ Thompson's Cndemic 
Diseases of South 

Endemic Diseases of the Southern States. By William H. 
Deaderick, M. D., Member American Society of Tropical IMedicine ; 
and LoYD Thompson, M. D., Charter Member American Association 
of Immunologists. Octavo of 546 pages, illustrated. Cloth, ^^5.00 
net ; Half Morocco, S6.50 net. Published March, 1916 

THE ONLY WORK OF ITS KIND 

This work records the experiences of two active practitioners and teachers 
right in the field, and thoroughly familiar with these diseases. Those diseases of 
special importance are given unusual consideration. Pellagra, for instance, is 
given eight chapters for its full consideration, while hookworni disease covers nine 
chapters and nialaj'ia eight. You get the etiology, pathology, clinical history, 
diagnosis, prognosis, prophylaxis, and treatment of each disease, presented from 
every angle, always bearing in mind the practical aim of the work — the application 
of the knowledge in daily practice. 



-4 SAUNDERS* BOOKS ON 



GET M. • THE NEW 

THE BEST t\ HI 6 r 1 C Si H STANDARD 

Illustrated Dictionary 



New (8th) Edition— 1500 New Words 

The American Illustrated Medical Dictionary By W. A. New- 
man Borland, M. D., Editor of "The American Pocket Medical Dic- 
tionary." Large octavo of 1 1 37 pages, bound in full flexible leather. 
Price, $4.^0 net ; with thumb index, ;^5.oo net. Published August, iqis 

KEY TO CAPITALIZATION AND PRONUNCIATION— ALL THE NEW WORDS 

Howard A. }^e\\ytM»D»t Professor of Gynecologic Surgery, Johns Hopkins University. 

" Dr. Borland's dictionary is admirable. It is so well gotten up and of such convenient 
size. No errors have been found in my use of it." 



Thornton's Dose=Book. P^^^h Edition 

Dose-Book and Manual of Prescription-Writing. By E. Q. Thornton, M.D., 
Assistant Professor of Materia Medica, Jefferson Medical College, Philadelphia. Post- 
octavo, 410 pages, illustrated. Flexible leather, ^2.00 net. Published September, 1909 

" I w\\\ be able to make considerable xise of that part of its contents relating to the correct 
terminology as used in prescription-writing, and it will afifqrd me much pleasure to recom- 
mend the book to my classes, who often fail to find this information in their other text- 
books." — C. H. Miller, Vi.Yy., Professor of Pharmacology , Northwestern University Medi- 
cal School. 

Lusk on Nutrition New (3d) Edition 

Elements of the Science of Nutrition. By Graham Lusk, Ph. D., Professor 

of Physiology in Cornell University Medical School. Octavo of 641 pages. Cloth, 

$4.50 net. PubUshed July, 1917 

" I shall recommend it highly. It is a comfort to have such a discussion of the subject." 
— Lfwellys F. Barker, M. T>., Johns Hopkins University. 

Camac's "Epoch-making Contributions** 

Epoch-making Contributions in Medicine and Surgery. Collected and 
arranged by C. N. B. Cam AC, M. D., of New York City. Octavo of 450 pages, illus- 
trated. Artistically bound, ^^4.00 net. Published January, 1909 

*' Dr. Camac has provided us with a most interesting aggregation of classical essays^ 
We hope that members of the profession will show their appreciation of his endeavors."— 
1 herapeutic Gazette. 



PRACTICE, MATERIA MEDICA, Etc. \s 

The American Pocket MediceJ Dictionary New (9th) Edition 

The American Pocket Medical Dictionary. Edited by W. A. NewiyIan Dor- 
land, M. D., Editor " American Illustrated Mtdical Dictionary." 693 pages. Flexible 
leather, with gold edges, $1.25 net; with thumb index, $1.50 net. April, 1915 

Strouse Cs Perry's Food Manual for Doctor and Patient 

A Food Manual for Doctor and Patient. By Solomon Strouse, A. B., M. D., 
Professor of Medicine, Post-Graduate Medical School, Chicago; and Maude A. 
Perry, B. S., Dietitian Michael Reese Hospital. i2mo of 270 pages. Cloth, $1.50 
net. PubUshed August, 1917 

Here the science of nutrition is detailed for the layman, and the physician finds 
his abstract theories translated into the terminology of the kitchen. Diets are given 
for diabetes (starvation treatment), gout, nephritis, high blood-pressure, kidney stone, 
diseases of the stomach, intestines, liver, gall-stones, tuberculosis, fevers, skin aflfec- 
tions, obesity, anemia, etc. There are in all 232 diets and menus, and 124 special 
recipes. 

Cohen and £shner*S Diag'nOSis. Second Revised Edition, 1900 

Essentials of Diagnosis. By S. Solts-Cohen, M. D., Senior Assistant Professor 
in Clinical Medicine, Jefferson Medical College, Phila. ; and A. A. Eshnp:r, M. D., 
Professor of Clinical Medicine, Philadelphia Polyclinic. Post-octavo, 382 pages ; 55 
illustrations. Cloth, $1.25 net. In Saunders^ Qiiestion-Compend Series. 

Morris* Materia Medica and Therapeutics. Seventh Edition 

Essentials of Materia Medica, Therapeutics, and Prescription-Writing. 
By Henry Morris, M. D., late Demonstrator of Therapeutics, Jefferson Medical 
College, Phila. Revised by W. A. Bastedo, M. D., Instructor in Materia Medica and 
Pharmacology at Columl)iaUniversityc 1 2mo, 300 pages. Cloth, ;5^i,25 \\&v. In Sounder^' 
Question- Co?npend Series. Published November, 1905 

Kelly's Cyclopedia of American Medical Biography 

Cyclopfdia of American Medical Biography. By Howard A. Ki:i,i.y, M. D., 
Johns Hookins University. Two octavos of 525 pages each, with portraits. Per set: 
Cloth, ^10.00 net ; Half Morocco, $13.00 net. Published April, 1912 

Oertel on Bright* s Disease illustrated 

The Anatomic Histological Processes of Bright's Disease. By Horst 
Oertel, M. D , Director of the Russell Sage Institute of Pathology, New York. Octavo 
of 227 pages, with 44 text-cuts and 6 colored plates. Cloth, $5.00 net. December, 1910 

Arnold's Medical Diet Charts 

Medical Diet Charts. Prepared bv H. D. Arnold, M. D., Dean of Harvard 
Graduate Medical School. Boston. Single charts, 5 cents; 50 charts, ^2.00 net ; 500 
charts, $18.00 net ; looo charts, $30.00 net. 

Eggleston's Prescription Writing 

Essentials of Prescription Writing. By Gary Eggleston, M. D., Instructor 
in Pharmacology, Cornell University Medical School. i6mo of 125 pages. Cloth, $1.00 
jjgt Published September, 1913 



i6 SAUNDERS' BOOKS ON PRACTICE, Etc. 



Slade's Physical Examination and Diagnostic Anatomy 

Physical Examination and Diagnostic Anatomy. By Charles B. Slade 
M. D., formerly of University and Bellevue Medical School. i2mo of 150 pages' 
illustrated. Second Edition— published September, 1916. Cloth, $1.25 net! 

Abbott's Medical Electricity 

Medical Electricity. By George Knapp Abbott, M. D., Dean and Pro- 
fessor of Physiologic Therapy and Practice, College of Medical Evangelists, Loma Linda, 
California. i2mo of 132 pages, illustrated. Cloth, ^1.25 net. April, 1915 

Stevens' Practice of Medicine New (loth) Edition 

A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., 

Professor of Pathology, Woman's Medical College, Phila. Specially intended for 

students preparing for graduation and hospital examinations. Post-octavo, 629 pages, 

illustrated. Cloth, $2.50 net. Published July, 1915 

Saunders' Pocket Formulary New (9th) Edition 

Saunders' Pocket Medical Formulary. By William M. Powell, M. D. 
Containing 1831 formulas from the best-known authorities. With an Appendix con- 
taining Posologic Table, Formulas and Doses for Hypodermic Medication, Poisons and 
their Antidotes, Diameters of the Female Pelvis and Fetal Head, Obstetrical Table, 
Diet-list, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from 
Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, etc., 
etc. In flexible leather, with side index, wallet, and flap, ^1.75 net. January, 1909 

De&derick on Malaria 

Practical Study of Malaria. By William H. Deaderick, M. D., Member 
American Society of Tropical Medicine ; Fellow London Society of Tropical Medicine 
and Hygiene. Octavo of 402 pages, illustrated. Cloth, ;^4.50 net; Half Morocco,. 
^6.00 net. Published NovembeE, 1909 

NileS on Pellagra second Edition— January, 1916 

Pellagra. By George M. Niles, M. D., Gastro-enterologist to the Georgia 
Baptist Hospital, Adanta. Octavo of 225 pages, illustrated. Cloth, $3.00 net. 

Hinsdale's Hydrotherapy 

Hydrotherapy. Bv Guy Hinsdale, M. D., Fellow Royal Society of Medicine 
of Great Britain. Octavo of 466 pages, illustrated. Cloth, $3.50 net. August, 1910 

Todd's Clinical Diagnosis Third Edition-October, 1914 

Clinical Diagnosis: A Manual of Laboratory Methods. By James Camp- 
bell Todd, M. D., Professor of Pathology, University of California. i2mo of 585 
pages, illustrated. Cloth, $2.50 net. 

This book gives you the exact technic, the precise procedure to follow down to the smallest detail. 
An extremely important section is that on the use of the microscope, giving you the various parts, how 
to prepare the material, make slides, and interpret the findings. The third edition has been brought 
right down to the minute. The contents include 70 pages on the therapeutic use of vaccines and sero- 
diagnosis, taking up the preparation of autogenous vaccines, Abderhalden's serum test for ectopic preg- 
nancy, the urease methods for urea, the Rimini-Burnam test for formaldehyd, Huntoon's method for 
spores, Ponder's stain for diphtheria bacilli, and the luetin reaction. 

"A distinct improvement on many of its predecessors of similar scope. It deals with all the examma- 
tions which the clinician may have to undertake in the course of his work. —Brtttsh Medical, Journal. 



